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0 New Facility 0 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> S7tl)1311Gi1 <br /> Site Address City Slate ZIP <br /> 704 N Jacli lotto,R(�;id Ripon CA <br /> APN Supervisor District <br /> Type of Servim 0 Application for ❑Consultation Q Change of Owner 0 Repairs or Remodel O Other <br /> Requested Operating Permit <br /> Comments S <br /> ifmodlefoodtrudsat tkt!nsePWteNumber V VIN <br /> pumperizttdt <br /> ContadTypes ❑Billing Party 0 Facility Owner ❑Facility Contact EJPropertyOwner (I Contractor ET Architect <br /> required <br /> RBllllrhg Party .4 Facility Owner Q Facility Contatt Property Owner ❑Contractor CT Architeu <br /> First Name Chwnchal Singh Cast name If rontradar,Indicate type and rrcense number <br /> Address 1467 Paseo De Las Flores city Encinitas State CA ZIP 92024 <br /> Phone Phone Email <br /> ❑Barg Party ❑Facility Owner U Facility Contact fl Property Owner ❑Contractor fl Arc hest <br /> First Name fast name if contractor,Indicate type and tkerae number <br /> Address city State ZIP <br /> Phone Phone Email <br /> 0 Willing Party ❑Facifrty Owner ❑Facility Contact fl Property Owner 11 Contractor fl Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> W WNG ACKWWLEDGEMENT:1,the undersigned property or business owner,operator or authorized agent of same,admowkdge 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 ideotilled on this <br /> form. <br /> I also certify that I have prepared this application and that the work be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes. <br /> Standards,STATE and FEDERAL taws <br /> AP PUCAM'SSIGMATuaE: �r_( la DATE: 11/12i202S <br /> IM PROPERTY/BUSINESS OWNER jU OPERATOR/MANAGER 0 OTHER AUTHORIZED AGE NT <br /> Title <br /> If APPLICANT Is not the SLUNG 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 authorite the <br /> release of anyand all results,geoteccnizal data and/or environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as snort as it is avallable and at the same time it is provided tome or my rc fMatalwe. <br /> Accepted By 1 Assigned To Linked FA ID +n k ] <br /> Dale 1 PE L 010 G F� 1 Reco m6cr ayment <br /> fl Cash ❑Check a Canllrmalton Y 11 `'1 1 o 2 6 Recehred By <br /> Rehr 07110/2024 <br /> R'�YMenrr <br /> EC,eIy=C <br /> No v 13 2025 <br /> r-1i/21 i Hfi40-H IDZP���►Y7'Y <br />