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□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Bari Pizzeria & Grill <br />Site Address City State ZIPLathropCa 95330 <br />APN <br />□ Consultation K Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number <br />4VK2518 1Z9Z1ET26RP475702 <br />□ BINing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />KI Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license number <br />Raj <br />Address City State ZIP <br />Manteca Ca 95336 <br />Email <br />Bari.pizza* ??yahoo.com <br />S Billing Party □ Facility Owner □ Fadlrty Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Rajwinder Kaur <br />Address City State ZIP <br />Manteca Ca 95336 <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />B] PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENTOPERATOR / MANAGER <br />Linked FA IDAssigned To <br />Fee <br />□ Check# <br />If APPLICANT is not the BILUNG 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 />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />iroject <br />m this <br />Contact Types <br />required <br />Last name <br />Singh <br />Email <br />BaripizzagrilKpgmail.com <br />Phone <br />2098151002 <br />Phone <br />209 983 2727 <br />L- <br />□ Confirmation It <br />Type of Service <br />Requested <br />Comments <br />Owner/Operator <br />Title <br />Change of ownership Same Location same Menu! <br />VIN <br />1772 Snowcap Dr <br />Phone <br />1772 Snowcap Dr <br />Phone <br />559 240 5022 <br />16201 S Harlan Road <br />Supervisor District <br />Record Number <br />Si?.3.G>0aa50 <br />Payment <br />Received <br />Existing Facility <br />^23 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, a< <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me'orVn’^b/igp^s^rs <br />fan*- <br />I also certify that I have prepared this application andthat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. A z r. Q/9n7A <br />APPLICANT'S SIGNATURE: DATE: 1 <br />“*pted“v c