Laserfiche WebLink
New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Browned Butter Bakery <br />Site Address <br />408 Rina Dr <br />City <br />Manteca <br />State <br />CA <br />ZIP <br />95337 <br />APN Supervisor District <br />Type of Service <br />Requested <br />g Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 11 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party El Facility Owner El Facility Contact El Property Owner 0 Contractor 0 Architect <br />First Name <br />Erica <br />Last name <br />Jabouri <br />If contractor, indicate type and license number <br />Address <br />408 Rina Dr <br />City <br />Manteca <br />State <br />CA <br />ZIP <br />95337 <br />Phone <br />209-4824399 <br />Phone Email <br />BrownedButterBakery209Agmail.com <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />I <br />First Name Last name If contractor, indicate type and license num er <br />Address City State ZIP <br />Phone Phone Email led <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license umber <br />Address City State ZI(A <br />Phone Phone Email <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAI;v4s. <br />APPLICANT'S SIGNATURE: <br />El PROPERTY / BUSINESS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />. <br />( 4-1-46, 601141, DATE: 8/3/2024 <br />OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By Assigned To f • F I in FA ID 75„,,,,,c_e.„ <br />Date <br />qi6/i /1 PE /601 kgC, <br />Fee Fee i kw o 0 3 g ..2.. gpcor.2c1 4Number <br />0 Cash 0 Check # /Confirmation # ) 07,1 61 <br />Payment <br />Received B <br />411g530 Rev 07/10/2024