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San Joaquin County Environmental Health Department <br /> Application Form ?(Z- 2L- <br /> Facility Name <br /> Jamba Juice <br /> Site Address 704 N Jack Tone Road City State ZIP <br /> Ripon CA 95366 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating PPeermiit� ` <br /> Comments {�(,/9 <br /> If mobile food truck or License Plate Number V VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party M Facility Owner ©Facility Contact ©Property Owner ❑Contractor M Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Chanchal Singh <br /> Address City State ZIP <br /> 1467 Paseo De Las Flores Encinitas CA 92024 <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facillty Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Archltect <br /> First Name Last name If contractor,Indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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 perf rmed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. r PAYMENT <br /> APPLICANT'S SIGNATURE: l/ l Y DATE: 11-20-2025ECEIV D <br /> lit PROPERTY/BUSINESS OWNER X OPERATOR/MANAGER 11OTHER AUTHORIZED AGENT <br /> If APPLICANT Is riot the BILLING PARTY,proof of authorization to sign is required Title NOV 2 5 2@25 <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 al!results,geotechnical data and/or environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIR0N&W4QAIQU1N COUNTY <br /> DEPARTMENT as soon as it is available and at the same time It is provided to me or my representative. ENVIRON-MENIAL <br /> HEALTH ENT <br /> Accepted By w Assigned Tof r ��_J Linked I SD r p a 00 /00 <br /> IdDate n E o) fee /� i ' Reco Number <br /> 11 Cash ❑Check q ❑Confirmation✓f Z'r $2� f ! g Payment <br /> r rn } (� �} { ✓ J Received By <br /> CLI d �1. # : I I U�� 1 13 — �I� J <br />