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Existing Facility New Facility San Joaquin County Environmental Health Department Application Form State ZIP CA 95376 Supervisor District Consultation 51 Change of Owner Repairs or Remodel Other License Plate Number VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect Property Owner Contractor Billing Party 0 Facility Owner Facility Contact Architect If contractor, indicate type and license numberFirst Name Last name Hernandez State ZIP CA 95304 Phone com Property Owner Contractor Architect Facility Owner Facility Contact Billing Party If contractor, indicate type and license numberFirst Name Last name State ZIPAddressCity EmailPhonePhone Architect Property Owner Contractor Facility Contact Facility Owner Billing Party Last nameFirst Name StateCityAddress 7025EmailPhonePhone 7/28/2025DATE: OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER Title Assigned ToAccepted By V'oO'Z Check it Cash Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required Application for Operating Permit City T racy City T racy If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Email TheURT racytagmail Date ~7 ■ 'Z-'g,- 2.5 Nicole Address 130 W 11th St Suite B APN Type of Service Requested Comments 15999 Tsirelas Dr Phone 5105792167 Facility Name The UR Site Address I— PE If contractor, indicate type and lic"n“ ZIP — * BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as ident form. 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, Standards, STATE and FEDERAL laws. ) I,, APPLICANT'S SIGNATURE: 7 y Tkst OPERATOR / MANAGER Linked FA ID Record NumberSP. 2. Payment . lf/\ Received ByC^Zf'^Confirmation it ■2-0^03^551