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(14 /fi:, /iv <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge thatiaidtg Ty tplIE: <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as 'den 460 <br />form. Nt <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 Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />XPROPERTY / 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 />2/25/25 <br />DATE: <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 d 4 r <br />eLs•-, At? <br />Address City State ZIP <br />L/ r,1 re 4,.., <br />Phone Phone Email S,41 I U 2 6 <br />kiO4 2025 <br />.. es <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name in -pare ActvemistilmiFiveTta -rp Le kiviri. Rs <br />Site Address. z48 W Fremont Street City Stockton State CA ZIP 95203 <br />APN Supervisor District <br />Type of Service <br />Requested <br />XApplication 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 />0 Billing Party Xacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party Xacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Janeen Last name Taplin If contractor, indicate type and license number <br />Address 737 W Montecito Avenue City <br />Mountain House <br />State CA ZIP 95391 <br />P(IgTo) 640-2617 Phone Email <br />@neapplewhips cam janeenp <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 />Accepted By Assigned To Linked FA ID (ma, La/ <br />W CLC-A <br />Date , <br />id. (i2 <br />PE - <br />/69. 0 a) <br />Fee <br />,,*/), (i1/0- '',1,1q•u tA9500c0-1- <br />131Z 091391 f co-rcrn aJzc7 4/q 9-/