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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name ACE SUSHI ©SAVE MART 100 <br />APN Supervisor District <br />^Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number <br />^Facility Contact Billing Party Facility Owner Property Owner Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Daniel <br />ZIP 90501 <br />Phone <br /> Facility Contact Property Owner Billing Party Facility Owner Contractor Architect <br />If contractor, indicate type and license numberLast nameFirst Name <br />CityAddress State ZIP <br />EmailPhonePhone <br /> Property Owner Contractor Architect Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br />1/21/2026DATE: <br /> PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br />121/1^ <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />payment <br />received <br />Last name <br />Amspaugh <br />Date <br />fi'l <br />Phone <br />310-730-5440 <br />City <br />RIPON <br />State <br />CA <br />Type of Service <br />Requested <br />Comments <br /> Application for <br />Operating Permit <br />Tn <br />Addre^2771 S. WESTERN AVE. <br />Email <br />janiel.amspaugl' ©acesushi.com <br />Si,eAdd-f%3 GOODWIN DRIVE <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required JAN 2 2 2021 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize theu^ J <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY COUNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.______________________________ENVIRONMENTAL <br />Record <br />Ta <br />“Torrance <br />ZIP95366 <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 t/ik the work to be rerformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />^OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />'PE 1(^3 <br />- AS^T. <br />paid (J 00&: ^56^^-