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San Joaquin County Environmental Health Department Application Form Facility Name TRACY QUICKLEY City State ZIPTRACY 95377CA APN Supervisor District Consultation Change of Owner Repairs or Remodel Other License Plate Number VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect filing Party Facility Owner Facility Contact Property Owner Contractor Architect If contractor, indicate type and license number State ZIP 95382CA Phone 1 'tYflafraserO?! 1@yahoo.com □Xacility Owner Facility Contact Property Owner Contractor Architect Billing Party If contractor, indicate type and license number ZIP 95377 Phone Email Contractor Architect Facility Owner Facility Contact Property Owner Billing Party If contractor, indicate type and license numberLast nameFirst Name City State ZIPAddress Phone EmailPhone DATE: OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER Title Linked FA IDAccepted By PE Check# Cash Rev 07/10/2024 Payment Received By Contact Types required 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 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. If mobile food truck or pumper truck X^plication for Operating Permit _______________ Site Address 2251 W GRANT LINE RD SUITE 128 First Name REULILYN New Facility Existing Facility Date ~l-2O-2lo ^Confirmation # Type of Service Requested Comments Last npANGAL|MAN Address 942 GETTYSBURGH ST State CA RgcW0W7 phon^09-345-1119 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. ALEFOSIO LAUMOLI JULY 10,2026 APPLICANT'S SIGNATURE: AZii5W GRANT LINE ST Phora209-914-7966 atyTRACY Assigned To I- X cs Fee First Name ALEFOSIO L3StTAUMOLI Citv TURLOCK