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---ryt .1 •-• II, <br />New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Destiny's Sweet Treats <br />Site Address 2101 west Tokay st City lodi State <br />Ca <br />ZIP 95242 <br />APN Supervisor District <br />Type of Service <br />Requested <br />IlApplication for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments PAYME <br />RECFn <br />JU1 1 7 <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party EkFacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Archittitti4OACIUNC <br />ENVIRONMEP <br />HEALTH DEPAR <br />0 Billing Party Dxfacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Destiny <br />Last name B urgess If contractor, indicate type and license number <br />Address 2101 West Tokay st City <br />Lodi <br />State <br />Ca <br />ZIP <br />95242 <br />Phone <br />(209)371-7864 <br />Phone Email <br />Destinybaptista@gmail.com <br />NT <br />/ED <br />2024 <br />UNTY <br />AL <br />MENT <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Pros <br />First Name Last name <br />Address City <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Prop <br />First Name Last name <br />Address City <br />Phone Phone Email <br />&t-f-tArn 4-1) <br />t7 <br />reL <br />e Tk4A, <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator ol <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projel <br />form. <br />I also certify that I have prepared this application and that the .ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Venfied by pelfFiller <br />Standards, STATE and FEDERAL laws. <br />07/10/24 APPLICANT'S SIGNATURE: .1_2esnnti _L>tArgegg DATE: <br />a PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <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 />Accepted By ., , Assigned To <br />ir- 4 <br />Unked FA ID rikert, 0,7D so 0 <br />Date <br />t . /41 i <br />PE PE 1 L c .‘,.,, Fee <br />P ig <br />Record Number <br />P a.4 00 704 <br />104_ qvic2o -q-2-