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££> Existing Facility□ New Facility <br />Application Form <br />Facility Name -Fountain Plaza <br />Site Address Tracy549 W. Clover Rd. <br />APN Supervisor District <br />HXhange of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />0 Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast nameJamale Carlyle <br />Address City State CABrentwood <br />\ -e 5 |c c\c S • com <br />□ Billing Party □ Facility Owner □ Contractor <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />EmailPhonePhone <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br />DATE: <br />□ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT Q PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />□ Check#?2oSq3S13□ Cash <br />Rev 07/10/2024 <br />San Joaquin County Environmental Health Department <br />P (2,0 3 2^0 33 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />ZIP <br />95376 <br />Phone <br />. Mo. <br />yNJ <br />State <br />CA <br />Type of Service <br />Requested <br />Comments <br />639 Auburn Way <br />Phone <br />C KkcVe <br />City <br />□ Architect <br />ZIP <br />94513 <br />Payment <br />Received By <br />Email <br />siCo-r\^ <br />□ Facility Contact <br />MAY 1 1 2026 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required JOAQUIN rn <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addrc hJFjSz'WIW MOtUNTf <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY EN <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ntAL IH DEPARTMENT <br />□ Property Owner <br />Assigned To <br />L \ r\ V>c\. ( S______ <br />^Confirmation tl <br />Accepted By <br />i—\ rxVxcxr <br />PE Fee <br />OR - <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge 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 identified on this <br />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 COUljP^^f^^^^ ’p <br />lX^XXd,XrL'aWi- CaAyk- DATE: 5/8/2026 RECEIVED