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Existing Facility Application Form ZIP 95304 Supervisor District □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number VIN □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor 8! Architect 8 Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number Phone Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact If contractor, indicate type and license numberFirst Name Last name City State ZIPAddress Phone Phone Email 12/03/2024DATE: □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER Title Linked FA ID IbC I W3□ Check II Rev 07/10/2024 Contact Types required 8 Application for Operating Permit Payment Received By San Joaquin County Environmental Health Department Last name Kathrani City Tracy City Tracy State California State California □ OPERATOR/MANAGER Record Number First Name Umang Address 470 W. Larch Road. Ste #6 Phone 510-488-3777 ZIP 95304 Assigned To VXCq/xO $________________ 457 u 5/Confirmation D 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <-> -J— /0 APPLICANT'S SIGNATURE: DATE: 12/03/2024 afehy authorizifWa, r kti^oLTH Accepted By Cc *c PE Facility Name, ______ib'vU'in*) Site Address 470 W. Larch Road. Ste #6 APN Date □ Cash Type of Service Requested Comments , This will be prep kitchen and not a full service kitchen. The person using the kitchen i<, If mobile food truck or pumper truck New Facility 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 addres^Ki release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY EN’ DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Fee 5 i K