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San Joaquin County Environmental Health Department <br />Application Form <br />Fosters Freeze (Arna food lie) <br />Site Adorru Cnv StMr a*95337906 W Yosemite AVe Manteca CA <br />AP-N <br /> «rp»r-. or Rtr->oecl D QttwrB t tatr ot O*o»rB CnM uliatc • <br />Uterae Plate Number <br />GCoMrMtoiOwi>«z <br />Cl Padlily c*wr>»r O I jrattj inntaci dconwartoi <br />tnlMehakjit <br />CM» <br />U FaoUy Cantau ConlractoiCl Sdlng Party O IWtf O»net <br />FrsS Nnir**USt ffatr*' <br />Stair ilP <br />PNanr <br />O Corz.tMtorO FocSty Cc«txlC siting Party <br />FirK Ntena last aa-T>B <br />ZIPGtyVtet-Aosrcu <br />I mai'Ft»cnr <br />V-UATf <br />C OPEPATOR i p OTHE R ALHHOHl’lD AGTtJT <br />llll» <br />'■r n ■: ?v <br />?^0\^(905 <br />T n Far Kt, OaMr <br />______ Manteca <br />'fosterfreeze92@ gmail. com <br />Type cd \ervcn <br />Hceuatted <br />Ccr-imenu <br />If r-otillr 'zoa trud or <br />pwrt'pui Uwcl <br /> ArdMec I <br />Supervise* Dittrkt <br />•s/^c-plicntc.-. far <br />OppraltfUt Pvnnil <br />If AAPIICAMT K not the SUlING PARTS proct ot authootatryi io MT'" ra rrijjrecJ <br />AtfTMOlWZATtOM 1ORCUA5I HWORVATIOP* When appicior, I, tKr owner ot itpe-alut ot tie proiietl, k«,i!ei al the atwe irt r addrms, hetrby aJihixue the <br />refawe at any and aflrruUtx gcdechi'-cal data amt/ee envtrwtmrntel/Mte dSsetMtnent Information tothr SAN KJ*QVWCOU*T’ LNVtRONMt NI At MIAUH <br />; DEPARTMENT as socin >. I It a. , lablr and a: tie tame tme d is provided lo rneomynton^entaTvr, <br />n Uinp Pally <br />iirM Uirne <br />(J l atiiily Onnrr <br />’ VIN <br />I tm*» <br />1538 rock spring ave <br />4086441800 j ~~ ' <br />ttate <br />ca <br />IMlllNG ACKNOVAf DGfMENT th? -ntjemgnrd prnpf-ny w tuiun«s Owner, operator or auttwrUed O* srSnnwvdf,' '.hat ai tite arvd.'O' fxTiyxt <br />tpetrtli (hVlRO»M(MTAl HfAltn (XPARTMf TT Aou'»i ttiwrei asu> U<«d with tin piu|« -1 Ot .utirlly w »tie h v-d Io •’» ur iw» buiinr-v. asMenlitled on IN» <br />fir hi <br />I <->9<rrt*i SlMt i»itr.» prn>»rM Ihi. yppllriitsw and;ywl ir» win* u. tc peilciruM wit t- chinu •<> auoaftarii* witnat SAM JOAQUIN COUNFr Oriluuncu Ccdut, <br />SL»r^»rth. STATl and PEN RAI laws \ AQ JO A POAOKAMICANTS SIGMATUM , j{ OATf 08/24/2025 <br />4/p«tOP<»T» / BUSIES OWNfF <br />, Facility Owner <br />I ai hue t <br />e contractor, Ind catc type and cenve numtier <br /> Architect <br />It tontr^criir, UnPrate t'rt’* Hint ilrente riMmbpr <br />1 Phone <br />I roniKi T,y>ai <br />| tesyu-rnd <br />jTjBiiiin< Parly <br />| O Arrhiteri <br />J_____ I U-l --■ -- -.ULI <br />I* toKilrat tew. In<l< ate t/pe and »•. m vr -iimb"’ <br />V’lV-oQ | <br />| Property Owner <br />®6 25 ®5 <br />c^nfejVr <br />J Phone <br /> Facttyr ContMi <br />^pr UOOl^im <br />' 95337 <br />| O Property Ownar <br />kaur