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San Joaquin County Environmental Health Department <br />Application Form 142050%22.w <br />Facility Name <br />Tiger's Yogurt <br />Site Address <br />4343 Pacific Avenue, Suite A3 <br />City <br />Stockton <br />State <br />CA <br />ZIP <br />95207 <br />APN Supervisor District <br />Type of Service <br />Requested <br />EI Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 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 />a Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />W Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Kathryn <br />Last name <br />Pruden <br />If contractor, indicate type and license number <br />Address <br />18650 Rodeo Drive <br />City <br />Lodi <br />State <br />CA <br />ZIP <br />95240 <br />Phone <br />209-482-4194 <br />Phone <br />209-471-2332 <br />Email <br />katiepruden@gmail.com <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 number <br />Address City State ZIP <br />Phone Phone Email <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 number <br />PA yii if , <br />Address City State ZIP <br />vi REC i E7 L, <br />Phone Phone Email <br />JAN 0 2 I, 25 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site biftv <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business at,j1,/eAlt el Co <br /> <br />g- JA/ Ty <br />form. L H DE R4 L-poN TA i -7.,,, , <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Co I vI des', ENT <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />LIC°WC/ <br />fil PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br />DATE: 12/23/2024 <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 LAA <br />Date 1 , <br />I a-12)01 a\,q <br />1/4/. ^/Ctik Assigned To ULA atek___ Linked FA <br />PE <br />).WIY)-- <br />Fee IA <br />fq 1 <br />Record Number azvoo -7 50 <br />a-1)6(n1/41-f-/q33/