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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 charges 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 prepared this a4li ation and that the k t e performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, ittAta Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: i2f PROPERTY / BUSINESS OWNER 0 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. DATE: 09/04/2024 At 003610 12 New Facility 0 Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Tita Dees Site Address 512 S. Hutchins Street City Lodi State Ca ZIP 95240 APN 04503018 Supervisor District 4 Type of Service Requested 12 Application for Operating Permit 0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other Comments Cottage Food Operator Permit 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 0 Architect 0 Billing Party 2 Facility Owner 0 Facility Contact 0 Property Owner CI Contractor 0 Architect First Name Deanna-Lynn Last name Eachus If contractor, indicate type and license number Address 512 S. Hutchins St. City Lodi State CA ZIP 95240 Phone 209-269-2490 Phone 209-403-0810 Email Titadees@protonmail.com 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 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 111 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email Accepted By e- n 7-- Assigned To Linked go , FA ID Date • q 1 li [its PE Fee Record Number RP2.'40 i 03/ CI Cash 0 Check 44 0 Confirmation # Payment Received By Rev 07/10/2024