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San Joaquin County Environmental Health Department Application Form Facility Name Pink Sparrow Bakery Site Address 1789 Foothill Vista Drive City Tracy State CA ZIP 95377 APN Supervisor District Type of Service Requested Application for gerating Permit 0 Consultation 0 Change of Owner POCI 0 Repairs or Remodel y 0 0th ...... ME.p Comments t4tVO C 1.-A -A PO 6 ilk SAN1 2O2 ,7024 : C11/ 0 If mobile food truck or pumper truck License Plate Number VIN VIN VI Cr Contact Types Billing Party Facility Owner required 0 Facility Contact 0 Property Owner 0 Contractor "H IOW cf N rL pil Billing Party A Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Tara Last name Magnan If contractor, indicate type and license number Address Same as above City State ZIP Phone 209-221-5407 Phone Email pinIcsparrowbakery@gmaiLcom 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 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP .. Phone Phone Email 0 BILLING ACKNOWLEDGEMENT: specific ENVIRONMENTAL form. I also certify that I have prepared Standards, STATE and FEDERAL APPLICANT'S SIGNATURE: 'PROPERTY / BUSINESS If APPLICANT is not the BILLING AUTHORIZATION TO RELEASE release of any and all results, DEPARTMENT as soon as it I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or proj HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on th this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Co laws. I A . DATE: 7/6/2024 s OWNER 0 OPERATOR ANAGER 0 OTHER AUTHORIZED AGENT PARTY, proof of authorization to sign is required INFORMATION: When applicable, I, the owner or operator of the property located geotechnical data and/or environmental/site assessment information to the SAN Is available and at the same time it is provided to me or my representative. Title at the above site address, hereby authorize the JOAQUIN COUNTY ENVIRONMENTAL HEALTH Accepted B (,_ ., Y .Cf r LotOS c 0 Assigned To &--- Ako,e_s li • Linked FA ID Date I 4s- -21i- PE , Icto I Fee it id9L 0 w. Record Number AP24100G3 9 0_161_ 18-,2_6/DGI-7 Piz vi cOul