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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />TEMPLE KITCHEN <br />City State ZIPMANTECACA 95337 <br />Supervisor DistrictAPN <br /> Change of Owner Repairs or Remodel Other Consultation <br />[^Facility Owner[^Billing Party Contractor Facility Contact Property Owner Architect <br /> Contractor Billing Party Facility Owner Facility Contact Property Owner Architect <br />If contractor, indicate type and license numberFirst Name SWARAJ <br />City State ZIPCA 95337MANTECA <br />Phone <br /> Contractor Facility Contact Property Owner Billing Party Facility Owner <br />Last nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br /> Facility Contact Property Owner Contractor Facility Owner Billing Party <br />Last nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />1 Linked FA IDAssigned ToAccepted By L <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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 />Phone <br />2096275196 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <-> ■ y-. ,, 06/23/2025 <br />APPLICANT'S SIGNATURE: z y x?-i- / <br />Fee <br />_____________ <br />Type of Service <br />Requested <br />Comments <br />[^Application for <br />Operating Permit <br />License Plate Number <br />SlteAdd§§0 N LINCOLN AVE <br />Email ... _ ..sdconsulting209@gmail.com <br />Date PE <br />7/ <br />[^OPERATOR / MANAGER <br />Last name q- <br />AtldrKS 660 N LINCOLN AVE <br /> Architect-^ <br />_____ <br />If contractor, indicate type and licenf^ifwiher '/V f* <br />□ Architey£P^7^. <br />If contractor, indicate type and license number