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K New Facility Existing Facility r San Joaquin County Environmental Health Department Application Form Facility Name Velley's Pizza Site Address City ZIP2064 Crestwood Ave, Suite D,95336Manteca APN Supervisor District S Change of Owner Consultation Repairs or Remodel Other ucCCc. License Plate Number VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect X Billing Party Facility Owner Facility Contact Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Babita Address State ZIPCA 95991 Phone Property Owner Contractor Billing Party Facility Owner Facility Contact ^Architect If contractor, indicate type and license numberFirst Name Last nameMohammad Sadiq Address State ZIP6060 Sunrise Vista Dr, Suite 2400B 95610CA Phone Contractor Facility Owner Facility Contact Property Owner Architect Billing Party Last nameFirst Name City StateAddress Phone EmailPhone DATE: OPERATOR / MANAGER OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER Title Linked FA IDAssigned To FeeDate Ct Check tt Cash Rev 07/10/2024 r lf 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 authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Contact Types required Application for Operating Permit If mobile food truck or pumper truck Email ms@msqeng.qom Email ms@msqeng.comPhone 916-620-4065 Type of Service Requested Comments 846 Graystone Ct Phone Record Number Payment Received By State CA Confirmation# (a Ma City Yuba City City Citrus Heights Accepted By Cc4> f rSe G Last name Sharma If contractor, indicate type and license number -------------- ► ________________________ ________ ________________________________________ Ml. BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge tK^t alFsite 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. /i / APPLICANT'S SIGNATURE: /7 ‘ U / . I □.ZO