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^Existing Facility□ New Facility San Joaquin County Environmental Health Department Application Form Facility Name THE CHAI LOUNGE ZIPCityStateSite Address 917 N CENTRAL AVENUE CATRACY 95376 Supervisor DistrictAPN " CTChange of Owner □ Other□ Repairs or Remodel□ Consultation License Plate Number VIN □ Architect□ Contractor□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner □ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberFirst Name ZIPStateAddress EmailPhone □ Architect□ Contractor□ Property Owner□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhonePhone □ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhonePhone DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER Title Accepted By FeeDate □ Check#□ Cash Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required □ Application for Operating Permit Phone Type of Service Requested Comments □ Facility Contact it name City icatipn aMthSt the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, 06/25/2026 PE \^oo2 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this applicat^ Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: ____________2 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^_______________________________________________ Linked FA ID y ft e>o-2 O'2'=H Payment Received By Assigned To L x r\Y~\cx/ s □ Confirmation #