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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Greekalicious <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />K Facility Owner Property Owner Contractor Billing Party Facility Contact <br /> Contractor Architect Billing Party Facility Owner Facility Contact Property Owner <br />If contractor, indicate type and license number <br />1399 E Yosemite Ave. <br />Phone <br /> Contractor Architect Facility Contact Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br /> Contractor Facility Contact Property Owner Facility Owner Billing Party <br />TIf contractor, indicate type and liciLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br />7/28/2025DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Linked FA IDAssigned ToAccepted By <br />FeeDate <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 />Last name <br />Dheer <br />ZIP <br />95336 <br />Email <br />dheer.arjun@gmpil.com <br />Phone <br />661-487-6104 <br />Record Number <br />City <br />Manteca <br />ZIP <br />95747 <br />State <br />CA <br />Type of Service <br />Requested <br />Comments <br />First Name <br />Arjun <br />Address <br />Cm-!- <br />City <br />Manteca <br />Owner <br />Title <br />Site Address <br />1399 E Yosemite Ave. <br />Supervisor District <br />KJ Application for <br />Operating Permit <br />License Plate Number VIN <br />State <br />CA <br />I Architect <br />C <br /> Archity^ <br />_______________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site an <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on th is T <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. \ I y' <br />APPLICANT'S SIGNATURE: A <br />$ PROPERTY / BUSINESS OWNER