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Gd New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Supervisor District □ Consultation □ Change of Owner [J Repairs or Remodel □ Other 'f h VIN □ Billing Party Q Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect Q Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number State CA □ Facility Owner □ Facility Contact □ Property Owner □ Contractor Q Architect□ Billing Party If contractor, indicate type and license numberLast nameFirst Name CQWEE State ZIP CA 94706 Phone 510-517-8567 □ Architect□ Facility Contact □ Property Owner □ Contractor□ Billing Party □ Facility Owner Last nameFirst Name State ZIPCityAddress ^?5EmailPhonePhone DATE:03 05 POPS □ OTHER AUTHORIZED AGENT□ OPERATOR/MANAGERQ PROPERTY / BUSINESS OWNER Linked FA IDAssigned To Cc Fee □ Check#□ Cash Rev 07/10/2024 City Manteca State Ca 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 ZIP 95377 ZIP 95337 Email CHANDIFOODSINC@CiMAIL.COM Phone 209-221-5544 Last name KAUR Email JHONCOWEEQ6@GMI \IL.COM City TRACY City ALBANY 'T? ; z If contractor, indicate type and license/ui^^/Ly Type of Service Requested -j-| Comments Facility Name ________Pokemoto_______________ Site Address 2235 W. Atherton Drive suite# 103 APN JHON Address First Name NAVJOT___________________________ Address 2600 PEBBLE CREEK CT___________ Phone 209-221-5544 509 RAMONA AVE Phone _______________________________________ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifiedorr 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. ■/,. APPLICANT'S SIGNATURE: ■' -'1! - Contact Types required Billing Party □ Application for Operating Permit J fjy c ( License Plate Number OWNER Title ( Record Number ._________fipzsrvi'isy Confirmation #__________9-/^1 Received By' Accepted By > Date _ PE 11 -7^^ Pm Aha sip