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Site Address APN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number VIN □ Billing Party CTFacility Owner □ Facility Contact ^/Property Owner □ Contractor □ Architect Q^Facility Owner□ Billing Party □ Facility Contact ^/Property Owner □ Contractor □ Architect If contractor, indicate type and license number Phone □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor First Name If contractor, indicate type and licen:Last name Address City State ZIP Phone Phone Email 5/10/2024DATE: {/PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER Linked FA IDAssigned ToAccepted By Record Number Contact Types required If mobile food truck or pumper truck 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. Email Jamba.acc@grappainv.i :om □ other authorized agent Mcmber/Partner Title r D Supplication for Operating Permit ZIP95366 ZIP 95366 Phone (209)248-8424 State CA Date Type of Service Requested Comments San Joaquin County Environmental Health Department ____ Application Form B A —k 704 N Jack Tone Rd Suite A Supervisor District City Ripon First Name Gulbahar Last name Saini □ Architect PAYfl/ia S,aleCA /Z3/2-7I d eSS704 N Jack Tone RD Suite A Fee City .Ripon MAY 1 3 __________________________SACN-5}Rn^CQJNTV B ILLI NG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site ano/or p/ofect'^TVIENT 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 COUN IY Ordinance Codes, Standards, STATE and FEDERAL laws. /G-JUL r APPUCANT'SSIGNATURE: Facility Name Grappa Investments LLC