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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />CHEF HITS THE STREETS <br />Site Address State ZIP 953043200 NAGLEE RD.#608 CA <br />APN Supervisor District <br />gS^hange of Owner Repairs or Remodel Other Consultation <br />License Plate Number VIN <br /> Contractor Architect Facility Contact Property Owner Billing Party <br /> Facility Owner Architect-ti Billing Party Property Owner Contractor Facility Contact <br />If contractor, indicate type and license number <br />State <br />CA <br />Phone <br /> Architect Contractor Facility Contact Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Owner Facility Contact Billing Party <br />If contractor, indicate type.Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br />PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT OPERATOR / MANAGER <br />Title <br />Accepted By <br />FeePE <br />\\oo2- <br />'oW HORev 06/12/2024 <br />.V<2v-ejS <br />Date <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />- "^Application for <br />Operating Permit <br />City <br />MOUNTAIN HOUSE <br />Phone <br />510-363-7616 <br />Type of Service fxQ <br />Requested <br />Comments <br />Email <br />CHEFHITSTHESTREETS@GMAIL.COM <br />Assigned To <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. _________________________________________ <br />Last name <br />BLANCO <br />Linked FA ID x <br />QqqT \ <br />ZIP <br />95391 <br />City <br />TRACY <br />I Facility Owner <br /> Architect <br />may <br />___________________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge mJ*r <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as id^W^drthis <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. 5/11/2026 <br />APPLICANT'S SIGNATURE:r>aT’:' <br />First Name <br />GARY <br />Address <br />295 W. BONNER DR