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San Joaquin County Environmental Health Department CtcIV�T <br /> Application Form '34IV <br /> p p E Q� ?� <br /> Facility Name <br /> Canteen @ Amazon SCK6 - Main Market [ryoEpq�N7' <br /> Site Address City State ZIP T <br /> 1500 E Grant Line Rd Tracy c, <br /> A 95304 <br /> APN Supervisor District <br /> Type of Service 0 Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> 'A;� <br /> Comments �eI� CGL&k (4a Vk I C)C ����a! <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types 0 Billing Party ❑Facility Owner 0 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and license number <br /> Nicole Rollins <br /> Address City State ZIP <br /> 2400 Yorkmont Road, Attn: Licensing Charlotte NC <br /> Phone Phone Ema`I, <br /> 704-328-5521 (office) hcole.RolllnS compass-usa.com <br /> ❑Billing Party ❑Facility Owner 2 Facility Contact 0 Property Owner ©Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Rob Daly <br /> Address City State ZIP <br /> 542 Mariposa Road Modesto CA 95354 <br /> Phone I Phone Email <br /> 209-346-1231 (cell) 209-287-3771 (offs ) rob.daly@compass-usa.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 10� ' DATE: WIV2024 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER B OTHER AUTHORIZED AGENT Licensing Manager <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> Date, _ Z PE I �OZ Fee 1 (0Recard�uup: IL-i Vv o <br /> 162.00 <br /> JH� `�.2oa� <br />