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0 New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Crumbl Manteca CitySite Address Manteca □ Consultation □ Change of Owner □ Repairs or Remodel □ Other Small take-out only cookie bakery. License Plate Number VIN □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Property Owner □ Contractor [^Architect□ Billing Party □ Facility Owner □ Facility Contact If contractor, indicate type and license number StateModesto ZIP 616 14th Street CA 95354 Phone □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact If contractor, indicate type and license numberLast nameFirst Name Address City State ZIP Phone EmailPhone □ Contractor □ Architect□ Facility Owner □ Facility Contact □ Property Owner□ Billing Party If contractor, indicate type and license numberFirst Name Last name StateAddressCity ZIP Phone EmailPhone DATE: Architect□ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENTU PROPERTY / BUSINESS OWNER Title Linked FA IDAssigned ToAccepted By y, Ja] petlraza Gehane Fahmy FeePEDate 5162-20-25 1601 Payment 196354102 Rev 06/12/2024 Contact Types required If mobile food truck or pumper truck Email plancheck@commercial; rch.com Last name Welinitz Phone 209 571 8158 APN 2683000^,8 Type of Service Requested Comments First Name Stacey Address 2235 Atherton Drive BLD A, Ste#A40 Supervisor District State CA (□■Application for Operating Permit 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Welinitz - 2/20/2025 ZIP 95337 ccElVpD If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required PCD O AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, herebyGflJ^zZthnrt^j. 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.______ ____________________ Pm^^QLIIKi ■m....^pa5elfe79 ■