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K New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Bao Bao Restaurant <br />City <br />Manteca <br />Supervisor DistrictAPN <br /> Change of Owner Repairs or Remodel Other Consultation <br />Please email to:TW_design511 ©yahoo.com if have any information or questions, <br />License Plate Number VIN <br />^Architect Contractor Billing Party Facility Owner Facility Contact Property Owner <br />X Facility Contact Billing Party Facility Owner Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last nameWanping Deng <br />CityAddress <br />Fremont <br />X Facility OwnerM Billing Party Contractor Facility Contact Property Owner Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Benny Lin <br />Address <br /> Contractor Architect Facility Owner Facility Contact Property Owner Billing Party <br />If contractor, indicate type and license numberFirst Name Last name <br />City State ZIPAddress <br />EmailPhonePhone <br />Dec 09.2024DATE: <br />X OTHER AUTHORIZED AGENT <br />Linked FA IDAccepted By <br />Fee <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />X Application for <br />Operating Permit <br />-PAYMENT <br />Received <br />Site Address <br />2235W.Atherton Dr Suite H <br />Date <br />I ~ |6t - 2.^ <br /> Cash <br />Email <br />Tw des i g n 511 |@yahoo.com <br />State <br />Ca <br />Email <br />'^BennyOI 2@vahoo.com <br />City <br />Dublin <br />Phone <br />510-366-6727 <br />Phone <br />510 239-6480 <br />Type of Service <br />Requested <br />Comments <br />Designer <br />Title <br />3878 Fallon Rd <br />Phone <br />39210 State St Suite 119 <br />Phone <br />Assigned To <br />$51(o a© <br />ZIP <br />94568 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required DEC 7 f] <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby ffGtKorVe tfit'z.'', <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR0rgy4^^.^AjJ H <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />ZIP <br />95337 <br /> Check lf <br />ZIP <br />94538 <br />â–¡ Confirmation # /731^56 <br />State <br />Ca <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. <br />APPLICANT’S SIGNATURE: W'ifM ----------------- <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />Record Number <br />_ AP24Q1 4-05 <br />Payment . i i <br />Received By A <br />State <br />Ca