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□ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />X Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />Phone <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name Last name <br />Address City State <br />2^5PhonePhoneEmail <br />Aseel Danan DATE: <br />□ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Linked PAID <br />1(^0 ( <br />□ Check #□ Cash <br />Rev 07/10/2024 <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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />C5 Application for <br />Operating Permit <br />Payment <br />Received By <br />Email <br />adanan@greenbergfarrow.com <br />City <br />Tracy <br />Last name <br />Aseel Danan <br />ZIP <br />95304 <br />City <br />Newport Beach <br />State <br />CA <br />State <br />CA <br />Record Number <br />__A?250/535 <br />i?4^inoConfirmation ti <br />3788 N Tracy Blvd <br />Supervisor District <br />First Name <br />.GreenbergFarrow________ <br />Address <br />4695 MacArthur Ct Ste 1450 <br />Phone <br />805-453-4039 <br />License Plate Number <br />APN <br />212-250-01 <br />Type of Service <br />Requested <br />Comments <br />^~New Facility <br />Facility Name <br /> Starbucks Coffee <br />Site Address <br />ZIP92660 <br />Accepted By___0 o <br />Date PE . , <br />l-lff-O-S i <br />Fee <br />------ <br />' H <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sit'e^l <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. ---------- , na/a a/ncAPPLICANT’S SIGNATURE: IgSSBr DATE: 01/14/25 <br />Greenberg Farrow - Associate <br />® other authorized agent Development Manager__ <br />Title <br />□ Architect <br />If contractor, indicate type ajW&w / <br />JT's/V'so <br />•:-.j — fcUTT'V I <br />Assi6"edToLW^s