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^t^New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />APN\ <br />^consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br />3 Facility Owner 3 Facility Contact Property Owner Contractor ArchitectE Billing Party <br />0 Billing Party 0 Facility Owner 0 Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />0 Facility Contact Property Owner Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license number <br /> Contractor Facility Contact Property Owner Billing Party Facility Owner <br />First Name Last name <br />City StateAddress <br />Phone EmailPhone <br />'ill be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,orm<:o <br />DATE: 11/11/2025 <br /> OTHER AUTHORIZED AGENT 0 OPERATOR/MANAGER0 PROPERTY/BUSINESS <br />Title <br />Linked FA ID <br />PE <br /> Confirmation # Check # <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />[2! Application for <br />Operating Permit <br />Last name <br />Chanthavong <br />Email <br />smacksaucetlc@gmail.com <br />State <br />California <br />State <br />California <br />ZIP <br />95206 <br />Email <br />smacksau cellc@grrlail.com <br />City <br />Stockton <br />City <br />Stockton <br />State <br />California <br />ZIP <br />95206 <br />Phone <br />N/A <br />Phone <br />N/A <br />Type of Service <br />Requested <br />Comments <br />Last name <br />Ridoloso Chanthavong <br />City <br />Stockton <br />First Name <br />Fullstar <br />Address <br />114 W 10th St <br />Phone <br />2096163213 <br />First Name <br />Shirly_______ <br />Address <br />114 W 10th St <br />Phone <br />2094874750 <br />Accepted <br />Date I I—,', <br /> CasH <br />z'pqs 2J0C, <br />^(00,^55 <br />Payment t <br />Received By <br />Facility Name <br />Southeast Street Grills________ ______ <br />Site Address __ i <br />l ’ Supervisor District <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 />AsaiepctiTqfl | t <br />Fee <br />SA*COUN ry <br />_______________________________________________________-BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowlM^fef^l bAject <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identfrfed <br />form. <br />I also certify that I have prepared this_aoplicalion and that the w; <br />Standards, STATE and FEDER^UfSws. <br />APPLICANT'S SIGNATURE:J <br />I Architect <br />PaymentIf contractor, indicate ty|n^^_ <br />I ZIP <br />JAW I]