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t <br />0 New Facility Existing Facility <br />City State ZIP1150 West Turner Rd.Lodi CA 95242 <br /> Consultation Change of Owner Repairs or Remodel <br />jyr <br />License Plate Number <br />0 Billing Party H Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br /> Billing Party Facility Owner Facility Contact Property Owner 0 Contractor <br />If contractor, indicate type and license number <br />ZIP <br />94070 <br />Phone <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner Contractor Architect <br />First Name Last name If contractor, indicate type and license numberLeslieBloudoff <br />Address City State ZIPPO Box 1088 Lodi CA 95242 <br />Phone <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor ® Architect <br />If contractor, indicate type and license number <br />ZIP <br />94710 <br />DATE: <br />(3 OTHER AUTHORIZED AGENT <br />Linked FA ID <br />( <br />Fee <br />/G?O I <br />LffU" Check# <br />Rev 07/10/2024 <br />San Joaquin County Environmental Health Department <br />Application Form <br /> Application for <br />Operating Permit <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 />Payment <br />Received By <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 j <br />Standards, STATE and FEDERAL laws? <br />APPLICANT'S SIGNATURE: <br />Email <br />jjameson@urbanb oc.net <br />City <br />Berkeley <br />Last name <br />Jameson <br />Email <br />dthornley@gasarc iitects.com <br />Email <br />leslie@nostravitawir ery.com <br />Phone <br />510-848-0895 <br />Phone <br />209-334-0274 <br />Date <br /> Cash <br />Type of Service <br />Requested <br />Comments <br />New Commercial Modular (Factory Built) kithen unit installed on site. <br />vIn <br />First Name <br />Jerry <br />Address <br />UrbanBloc Inc. 2350 Morse Blvd. <br />Phone <br />510 798 8007 <br />Facility Name <br />Nostra Vita Winery Pairing Kitchen <br />Site Address <br />Architect <br />Title <br />First Name <br />Douglas <br />Address <br />729 Heinz Ave., Ste 1 <br />Phone <br />jjj^pplication to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />— 10/24/24 <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />Last name <br />Thornley <br />Accepted By <br />____(J t X- V <br />' PE <br />’2 20^ <br />' “ ''Wf/y f <br />0 Architect <br />APN <br />029-020-02 <br />Assigned <br />City <br />San Carlos <br />State <br />CA <br />Supervisor District <br />4 <br />State <br />CA <br />Confirmation #