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□ New Facility □ Existing Facility <br />Application Form <br />Facility Name <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />Sushi <br />VIN <br />3 Billing Party □ Facility Owner B Facility Contact □ Property Owner □ Contractor □ Architect <br />0 Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />City State ZIP <br />MN 55121Eagan <br />Phone <br />□ Billing Party 0 Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />State ZIPMN 55121 <br />Phone <br />□ Billing Party □ Facility Owner 0 Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />State ZIPMN 55121 <br />04/10/2026DATE: <br />0 OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER <br />Linked FA IDAssigned ToAccepted By <br />Fee <br />□ Check #□ Cash <br />APR I 3 2026Rev 07/10/2024 <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 />Contact Types <br />required <br />Email <br />Licenshg@sushiavenue com <br />San Joaquin County Environmental Health Department <br />Last name <br />Aung <br />Last name <br />Aung <br />Email <br />Licensing@sushiavenue.com <br />Email <br />Licensing@sushiavenue.com <br />City <br />Eagan <br />State <br />CA <br />License Plate Number <br />N/A <br />Phone <br />651-294-7001 <br />Last name <br />Fujii <br />ZIP <br />95337 <br />City <br />Menteca <br />Type of Service <br />Requested <br />Comments <br />Prepackaged Sushi inside Rancho San Miguel Grocery Market <br />If mobile food truck or <br />pumper truck <br />Site Address <br />2301 West Atherton Dr <br />APN <br />First Name <br />Marcus <br />Address <br />895 Blue Gentian Road Suite 6 <br />Phone <br />First Name <br />Marcus <br />Address <br />895 Blue Gentian Road Suite 6 <br />Phone <br />(651)294-7000 <br />SUSHI AVENUE, LLC <br />Supervisor District <br />Marcus Aung <br />0 Application for <br />Operating Permit <br />□ other authorized agent Operations corordinator <br />Title <br />First Name <br />Shingo <br />Address <br />895 Blue Gentian Road Suite 6 <br />Phone <br />(651)294-7000 <br />AN JOAQUIN COUNI Y <br />ENVIRONMENTAL <br />HEALTH DEPARf MEN I <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 ENVIRONMENTAL 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, <br />Standards, STATE and FEDERAL laws, <br />APPLICANT'S SIGNATURE: /W&'LCMd' X>{< <br />Date <br />1'7^7 <br />PAYMENT <br />RECEIVED <br />City <br />Eagan <br />PE l(oC2J <br />□ Confirmation # I 4 j "Sved By