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^.Existing Facility□ New Facility <br />0-7-7 <br />Facility Name THE CHAI LOUNGE <br />Site Address City State917 N CENTRAL AVENUE ZIPCATRACY 95376 <br />APN Supervisor District <br />'■^Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license number <br />Address State ZIP <br />Phone <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name Last name <br />Address City 2026State <br />Phone Phone Email <br />DATE: <br />□ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />Accepted By <br />Date Fee <br />□ Cash □ Check tt <br />Rev 07/10/2024 <br />San Joaquin County Environmental Health Department <br />Application Form <br />□ Application for <br />Operating Permit <br />If APPLICANT is not the BILLING 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 />Contact Types <br />required <br />Type of Service <br />Requested <br />Comments <br />If mobile food truck or <br />pumper truck <br />Phone Email <br />□ Facility Contact <br />it name <br />City <br />_____________________________________ ___________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or pri^ecA^ <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 />form. <br />I also certify that I have prepared this applicaty <br />Standards, STATE and FEDERAL laws. <br />APPLICANTS SIGNATURE: ____________2 <br />icatipn and.that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />n.~. 06/25/2026 <br />If contractor, indicate type and liclrW»H <br />PE <br />Assigned To Linked-FA ID <br />Payment <br />Received By (.2 Confirmation # Z22.q~1%S'e>s