Laserfiche WebLink
New Facility <br />Facility Name KRISPY KRUNCHY CHICKEN EL DORADO <br />Site Address <br />Supervisor DistrictAPN <br />Ef Change of Owner Other Repairs or Remodel Consultation <br />VINLicense Plate Number <br /> Contractor Architect Property Owner■0 Billing Party Facility Contact Facility Owner <br /> Architect Contractor Property OwnerQ'Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberLast name <br /> Architect Contractor Property OwnerGf Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license number <br /> Architect Contractor■0 Facility Contact Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license number <br />Phone <br />DATE: <br /> OTHER AUTHORIZED AGENT'ROPERTY / BUSINESS OWNER <br />Assigned To <br />Date <br /> Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />Payment <br />Received By <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 />FT <br />713 EL DORADO ST <br />Email <br />iohn@loopneiqhborhood.com <br />Email <br />ashwin@loopneigfiborhood.com <br />Email <br />ashwin@loopneigl|iborhood.com <br />City <br />UNION CITY <br />City <br />UNION CITY <br />City <br />STOCKTON <br />ZIP <br />94587 <br />ZIP <br />94587 <br />State <br />CA <br />State <br />CA <br />State <br />CA <br />Phone <br />510600543 <br />Phone <br />510-270-3437 <br />Phone <br />510-2703437 <br />Last name <br />ELLIS <br />State <br />CA <br />Type of Service <br />Requested <br />Comments <br /> Application for <br />Operating Permit <br />This is an ownership change for Krispy Krunchy Chicken from Poppy Markets LLC to EATON FOODS, INC <br />Last name <br />GOYAL (EATON FOODS ,INC) <br />City <br />UNION CITY <br />Address <br />1320 DECOTO RD, SUITE JOO <br />Phone <br />510-270-3483 <br />First Name <br />VARISH____________________ <br />Address <br />1320 DECOTO RD, SUITE 200 <br />Phone <br />510-270-3483 <br />Z,P94587 <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 applicatidiyapdjhat the woi <br />Standards, STATE and FEDERAL laws. / A ~ <br />APPLICANT'S SIGNATURE: ________ <br />EJ OPERATOR / MANAGER <br />Accept By <br />DaAfa/^|P7^A <br /> Check It <br />Address1320 DECOT RD, SUITE 200 <br />irk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />[2^202.6 ■ <br />•_________ <br />Title <br />First Name J0HN <br />(^Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form Feb 05 ° <br />fest <br />First Name EAT0^j Fq0DSi |NC <br />Record NumberSB. 30)01^57 <br />^Co^lrmstipp « 11 jfl