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BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly cnar: -s associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepare ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, d a F pplication a dh DATE: 10/30024 PROPERTY / BUSINESS OWNER • OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Title 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. Standards, STATE and FEDERAL I APPLICANT'S SIGNATURE: I D New Facility P Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Poppy Coffee Site Address_ 4u0 E Kettleman Ln STE 10 91 d i StatA 618240 APN Supervisor District Type of Service Requested 0 Application for Operating Permit 0 Consultation thane of Owner 0 Repairs or Remodel 0 Othr. tjA Y/1/7C Comments REC N EiVE.i OCT 0 9 2ny, If mobile food truck or pumper truck License Plate Number VIN Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor /_,,EN "4/- /FR Cn Olvm, - UN - OBilling Party . Facility Owner iFacility Contact 0 Property Owner 0 Contractor 0 Architect First Name . Paige Last name Woodward If contractor, indicate type and license number Address 102 Villa Point City Stockton State CA ZIP 95209 Phone 209-817-6987 Phone Email Poppycoffee209 pgmail.com 0 Billing Party 0 Facility Owner 0 Facility Contact 110roperty Owner 0 Contractor 0 Architect First Name J. and V Teresi Last name If contractor, indicate type and license number Address P.O box 936 City Lodi State CA ZIP g5241 Phone Phone Email 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email Accepted By r g vt, 2_ Assigned To _r- ., I ,.. Linked FA ID Date id q I ill PE . RD 01 Fee A ITZ. Record Number s 0 Cash 0 Check # /Confirmation # i 367 2.7D S•c13--- — Payment Received By Rev 07/10/2024 FR6L-Oicl