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New Facility San Joaquin County Environmental Health Department Application Form Facility Name TANDOORI FLAVORS Site Address City State ZIP551 W. CLOVER RD.TRACY CA 9533Z- APN Supervisor District214-21-07 Consultation Change of Owner Repairs or Remodel Other TENANT IMPROVEMENTS. ADDING NEW EQUIPMENT FOR NEW BUSINESS. License Plate Number VIN X Billing Party X Facility Contact X Architect Facility Owner Property Owner Contractor X Billing Party Facility Owner Facility Contact Property Owner Contractor Architect First Name If contractor, indicate type and license numberRAVNEET KAUR OR SANDEEP KAUR Address City State ZIPCA551 W. CLOVER RD.TRACY ■05^37 Phone Phone Email209-683-6429 singharashdeep683@gmail.com X Facility Contact Contractor Billing Party Facility Owner Property Owner Architect If contractor, indicate type and license numberFirst Name Address City State ZIP615 13TH STREET STE. B4 CA 95354MODESTO Phone Phone Email 209-345-0912 X Architect Facility Contact Property Owner Contractor Billing Party Facility Owner If contractor, indicate type and license numberFirst Name KEN KAESTNER / KAESTNER ARCHITECT Address City State ZIPP.O. BOX 1777 EMPIRE CA Phone Phone Email209-450-0085 KKaestner.com 08-22-24DATE: X OPERATOR/MANAGER OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER Title Assigned To Linked PAID PE I o ( Cash Check H Rev 07/10/2024 RICARDO ORTIZ / ORTIZ DESIGN GROUP 1 ricardo@ortizdesigngroup.com | 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 Contact Types required X Application for Operating Permit Payment Received By Type of Service Requested Comments ■ 28 202^ 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. RAvNE£T KAUR <9R SANPHEP KAUR APPLICANT'S SIGNATURE: Record Number_______I ^Confirmation# Fee sib