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San Joaquin County Environmental Health Department Application Form Supervisor District ^(Repairs or Remodel□ Consultation □ Change of Owner □ Other VIN ^(Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor ^(Billing Party □ Facility Owner □ Contractor□ Facility Contact □ Property Owner □ Architect If contractor, indicate type and license number Phone coin □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor Phone com □ Contractor □ Architect□ Facility Owner □ Facility Contact □ Property Owner□ Billing Party First Name Last name State ZIPCityAddress EmailPhonePhone DATE: ^PROPERTY / BUSINESS OWNER IRATOR / MANAGER □ OTHER AUTHORIZED AGENT □ Title Linked FA IDAssigned ToAccepted By Fee Contact Types required If mobile food truck or pumper truck Email edestacoshop@gmail Last name Mendoza 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.___________________________________________________ Last name De La Cruz ZIP 95358 Email emddesiqns@qmai ZIP 95834 City RIPON State CA State CA State CA ^(Architect DESIGNER ’performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, 08/06/24 'and that the work First Name Edelmira Address 1968 San Ramos Way, Phone (209) 241 - 7537 C Ct V Tw e'5 Hi PE First Name Enrique_______________ Address 3760 MIRTOON SEA AVE Phone (408)427-2146 ^^Application for Operating Permit iM €VVlt/ -f License Plate Number ^Architect DESIGNER If contractor, indicate type and license number Daiep-6-2^- rikoi If contractor, indicate type and license nuj Facility Name EDE S TACO SHOP Site Address 424 W. MAIN ST., APN 759-271-03 Type of Service Requested Comments ■^O ___I 6%/ City Modesto, CitySACRAMENTO 0? ___________________________________________________________________________________________________________________________ ‘ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all I^J- q specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as'ldte^fi.^ASffly/ ‘ * form. — I also certify that I have prepared this applicetii Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: ZIP 95366