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New Facility □ Existing Facility <br />Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel H Other <br />License Plate Number <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />H Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect0 Billing Party <br />If contractor, indicate type and license number <br />Phone <br />□ Architect□ Property Owner 0 Contractor□ Facility Owner □ Facility Contact□ Billing Party <br />Phone <br />□ Contractor 0 Architect□ Facility Contact □ Property Owner□ Facility Owner□ Billing Party <br />If contractor, indicate type and license number <br />□ OPERATOR/MANAGER0 PROPERTY / BUSINESS OWNER <br />Linked FA IDAssigned To <br />FeePE <br />□ Check II <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 />□ Application for <br />Operating Permit <br />Payment <br />Received By <br />Email <br />designersconsorti jm559@gmail.com <br />ZIP <br />93625 <br />ZIP <br />95377 <br />ZIP <br />93612 <br />Last name <br />VAGARWAL <br />Last name <br />KAUR <br />City <br />TRACY <br />City <br />Cl OVIS <br />State <br />CA <br />Phone <br />559-313-8494 <br />Email <br />AMRITANDOORI@.GMAIL.COM <br />Email <br />INFO@RANIHOI.DING.COM <br />City <br />FOWLER <br />State <br />CA <br />Last name <br />SINGH <br />City <br />STOCKTON <br />State <br />CA <br />Confirmation # <br />Record Number <br />AP 24 QXD893 <br />0 OTHER AUTHORIZED AGENT ARCHITECT <br />Title <br />First Name <br />RENU___________ <br />Address <br />280 Shaw , Suite c <br />Phone <br />559-367-8077 <br />First Name <br />JASDEEP __________ <br />Address <br />670 S KANDARIAN AVENUE <br />Phone <br />First Name <br />AMRITPAL <br />Address <br />4703 WINDY COVE LANE <br />Phone <br />Facility Name <br />TANDOORI PIZZA RESTAURAN^_ <br />Site Address <br />5756 PACIFIC AVENUE, SUITE # D5 <br />APN <br />102-270-100 <br />Type of Service <br />Requested <br />Comments <br />PROPOSED TENANT IMPROVEMENT PLANS FOR TANDOORI PIZZA <br />VIN <br />If contractor, indicate type and license number <br />1045088 <br />State <br />CA <br />□ Cash <br />San Joaquin County Environmental Health Department <br />Application Form C£i^£d <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMEN FAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <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,