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^fe-Ejfisting Facility San Joaquin County Environmental Health Department Application Form Facility Name American Legion Hall Post 249 Site Address 220 E. Yosemite Ave. Supervisor District Consultation Change of Owner K Repairs or Remodel Other License Plate Number VIN Billing Party Facility Owner Facility Contact KI Property Owner K Contractor Architect 53 Billing Party Facility Owner KJ Facility Contact Property Owner 53 Contractor Architect Phone Email Billing Party XI Facility Owner Facility Contact [X Property Owner Contractor Architect First Name If contractor, indicate type and license numberJeff Address City ZIP 105 E. Yosemite Ave.Manteca 95336 Phone Email Billing Party Facility Owner Property Owner Contractor Facility Contact Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP PhonePhone PROPERTY / BUSINESS OWNER Assigned To Linked FA IDAccepted By PEDati 1 (co I Cash Check# Rev 07/10/2024 Contact Types required Application for Operating Permit Payment Received By Phone 209-456-6263 |jeffaksland@gmai|l.com City Manteca ZIP 95336 ZIP 95336 City Manteca State CA >75 0104 OTHER AUTHORIZED AGENT Record Number ^i^New Facility Private kitchen remodel for American legion Hall ADA upgrades If mobile food truck or pumper truck 123 D'Arcy Pkwy Phone 209-679-3223 mike@dlbgc.com Contractor Title If contractor, indicate type and license number 745244 State CA APN 22107001 Type of Service Requested Comments Last name Aksland Confirmation # Last name Degroot Fee 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 address, hereby authorlTt flj release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRCff^q^TA HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. „ V oESo"' OPERATOR/MANAGER >4^1 I I 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. o,.^ APPLICANT'S SIGNATURE: MirhAAl PlPrirnnt^' - DATE: First Name Michael Address State CA