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0 New Facility ria Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />AMERICAN NAWABS <br />Site Address <br />2185 N TRACY BLVD 2185 <br />City <br />TRACY <br />State <br />CA 95376 <br />phi Supervisor Distric <br />Type of Service <br />Requested <br />0 Appacatiora for <br />Operating Permit <br />0 Corsiatation li3 Changeof Zimmer 0 Rbes or Remodel 0 Other <br />Please remove Shaik Ejaz,Sarni DoosiMasi Doostfahim Roheen and add Sreedhar Dulla <br />If mobile food truck or <br />pumper truck <br />I License Elate Nt.14111 <br />Contact Types <br />reqcared <br />0 Wing Party riii Facility Owner 0 Facility Contact 0 Property Owner 1 0 Contractor 0 Architect <br />0 Bilking Party 0 F &clay Cf:TtMer 0 Facially 1 0 Pr y C i e 0 Contractor 0 ArcIdtect <br />First Name <br />SREEDHAR <br />Last name <br />DULLA <br />it contractor, htate type and license number <br />Address 1 <br />696 W DO1AINEY DR 'MOUNTAIN <br />City <br />HOUSE <br />State <br />CA <br />ZIP <br />95391 <br />Phone <br />408-5945560 <br />Phone Email <br />sreedulla@hotm oom <br />0 Baling Partf 0 Facility Onnifer 0 Facbly Contact 0 Property Owner <br />Last name PA) <br />0 Contractor 0 ArchiteC <br />FF55 Narre and <br />C C <br />If contrador, indicate type <br />Adri'ess City State 1 ZIP / <br />AP <br />Phone Ernal 15 20' SA N t..! ,„ . , 4 <br />0 Cointractor EN V‘ QUIN <br />4211 -PtiDN 4/1 b DE-pil iprivirli <br />01 BiIFFOg Psstt„ 0 Facility Owner 0 Facility Contact 0 P oper y Dinkel' <br />First Name Last name If contractor, t 1kate type and license number <br />Address 1 City State EP <br />Rhone Phone <br />i <br />Email <br />1 <br />1 <br />BILLING ACICNOINILEDGEMENT: I. the undersigned property or business owner, operator or authortred agent of same, a f.ncvihedge that ail site and/or project <br />specific ENVIRONMENTAL HEALTH IMPARTMENT hoLiny charges associated with this project or activity will be biked to me or my &minims as identfied or this <br />form. <br />also that I have prepared dins application and that the wort to be performed will be done is aiccordance .widt, an SAN JOAQUIN COUNTY entffirsance Codes, <br />Standards, STATE and FEDER/77_ <br />APPLICANT'S SIGNATURE: <br /> <br />DATE; 04114/2025 <br /> <br />0 PROPERTY / BUSINF_SS OWNER OPERATOR IMANLkiEll 0 OTHER AUTHORIZED A'aNT <br />Tide <br />If APPLICANT is not the BILLING PARTY, proof of a otlae. to tiv, is required <br />AUTHORIZATION TO RELEASE WaFORNMITION; 'Often applicabte. the owner or ape, .L. of the Factpentr 4,c,e-ated at the ataare sae address, heffeby authorize the <br />release of any and al resialts, geotechnical data and/or ererirorterreritalisite assessment information to the SAN KAMAN COLINTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my retwanierritartive, <br />Accepted <br />BY K Ct-a-12-a.frv*V2, L. AlsImk''Tc' R a.a.k.a.A..4.N.e. L. linked <br />FA ID FA 00 al (0 3 5 <br />Date4.15.a5 PE 1(poa Fee$1.702.%4 ReceldNunngrK a 5o1 003 <br />0 Cash 0 Chem If 1,,iCerfirnIalw X _N9938114 :=By6er <br />Rev 07/10/2024