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□ New Facility 8 Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Site Address ZIP 95304 Supervisor District □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number □ Facility Contact □ Property Owner □ Contractor 8 Architect□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect8 Billing Party □ Facility Owner □ Facility Contact If contractor, indicate type and license number Phone Email /^.Architect□ Property Owner □ Contractor□ Facility Owner □ Facility Contact□ Billing Party If contractor, indicate type and license numberLast name. □ Contractor□ Facility Contact □ Property Owner□ Facility Owner Last nameFirst Name City StateAddress Phone Phone Email □ OTHFR AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER Title Assigned ToAccepted By / □ Cash □ Check ft Rev 07/10/2024 Type of Service Requested Contact Types required 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. If mobile food truck or pumper truck 8 Application for Operating Permit Payment Received By State California State California Date Last name Parvathaneni City Tracy ZIP 4 2976 Grant Line Road APN Existing restaurant with the installation of a new hood system. All other items remain as is VIN City Tracy First Name Rajasekhar______ Address 2976 Grant Lin $Ro ad Phone (510)458-1873 --PE BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge tfiall^Mra specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifiedc 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. <-» /) HQ/OQ/OHOR APPLICANT'S SIGNATURE: 004^ DATE: U9/Z9/Z(JZO □ OPERATOR/MANAGER Email P ZIP 95304 Phone □ Billing Party °y_______ City ,__ _ . c)vx ' "Vdt. S'O Linked FA ID FA ^2.3 11 3. Record Number SQ2C5<Z>153\ Confirmation ft C3| □ Architect If contractor, indicate type an. Fir^Name Address Phone