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0 New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />0 Billing Party □ Facility Owner 0 Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />Phone <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />12/15/2025DATE: <br />□ PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />FeeDateI ^5 <br />Rev 06/12/2024 <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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />0 Application for <br />Operating Permit <br />Email <br />support@kenstonfarms.com <br />Last name <br />Preston <br />City <br />Pelham <br />City <br />Manteca <br />VIN <br />3ALACWFC4SDVR6437 <br />ZIP <br />95337 <br />ZIP <br />35124 <br />State <br />CA <br />License Plate Number <br />IN 3790162 <br />State <br />AL <br />Record Number4pasoaqas <br />First Name <br />Sarah <br />Address <br />1053 Commerce Blvd <br />Phone <br />256.404.1415 <br />Facility Name <br />Kenston Farms DBA Wedge Hollow Farms (Ad Partner) <br />Site Address <br />1356 Bass Pro Dr <br />APN <br />22455037 <br />Type of Service <br />Requested <br />Comments <br />PE | dtb- <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <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 />BOTHER AUTHORIZED AGENT Admin