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New Facility E Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Grocery Outlet Of Manteca <br />Site Address fSianteca dX ^3361391 E Yosemite Ave <br />APN Supervisor District <br /> Consultation Change of Owner Repairs or Remodel Other <br />4license Plate Number <br />] Property Owner Contractor Architect <br />K Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />last name CamllO If contractor, indicate type and license number <br />Address City State3400 Sol Ln ukiah Ca <br />Phone <br /> Billing Party 03 Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, Indicate type and license numberFirst Name Last nameAntonio Carrillo <br />Address City State3400 Sol Ln Ukiah Ca <br />Phone <br />M Facility Contact Billing Party Property Owner Contractor Architect Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />Address Ukiah <br />Phone <br />DATE: <br /> OTHER AUTHORIZED AGENT <br />Title <br />linked FA IDAssigned ToAccepted By <br />Fee <br /> Confirmation If Check II <br />Rev 07/10/2024 <br />JAN 0 2 2026 <br />payment <br />RECEIVED <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 cnvlronmcntal/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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />(X Application for <br />Operating Permit <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Payment <br />Received By <br />Email <br />marieemyaa@grriail.com <br />Zl95482 <br />Email <br />Tcarrillo.mmccoy(g)gobmio.com <br />Email <br />tcarrillo.mmccoy@gobmio.com <br />ZIP <br />95482 <br />Phone <br />707)391-8474 <br />Phone <br />(707) 380-7161 <br />________ <br />My a <br />263 Arlington Dr <br />McCoy <br />City <br />f|A- Q € O O ^0% <br />R—.^Ql -q-7 | <br />Received By <br />State Ca <br />ZIP95482 <br />Oa,ci i / ill'll 2-6 <br /> Cash <br />| KI Facility Contact <br />Type of Service <br />Requested <br />Comments ■ <br />Existing grocery retail food facility- change in operator c <* <br />VIN <br />OS Billing Party | K Facility Owner <br />Phl707)380-7161 <br />F.rstName AntOniO <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 thisauphrttion and that Us^work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws'//fWl z? ! f 12/18/2025 <br />APPLICANT'S SIGNATURE: /|/// <br /> PROPERTY / BUSINESS OWNER W OPERATOR / MANAGER