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K New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Cold Stone Creamery Site Address City State Lathrop CA APN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor ® Architect □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor C3 Architect If contractor, indicate type and license numberFirst Name Last name YehJanice City Cupertino Phone □ Contractor□ Billing Party K Facility Owner □ Facility Contact □ Property Owner □ Architect If contractor, indicate type and license numberFirst Name Surmeet State ZIPAddressCity16722 Golden Valley Pkwy CALathrop 95330 Phone □ Contractor□ Facility Owner □ Facility Contact □ Property Owner□ Billing Party If contractor, it*Last nameFirst Name City StateAddress Phone EmailPhone DATE: □ OPERATOR / MANAGER S OTHER AUTHORIZED AGENT□ PROPERTY / BUSINESS OWNER Linked FA IDAssigned To FeePEDate □ Check#□ Cash Rev 07/10/2024 Contact Types required If mobile food truck or pumper truck □ Application for Operating Permit 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 janice@adaptivelarch.us Email ks u rmeet@hotrpail.com Phone (951) 208-5410 Phone (MO) 684-3226 Accepted By Type of Service Requested Comments Plan review for tenant improvement project VIN 16722 Golden Valley Pkwy Supervisor District Architect Title for □ Confirmation « Last name Sandhu Address 20111 Stevens Creek Blvd Ste 280 ZIP 95330 ZIP 95014 Payment I Received By( □ Arch^ect ... _______________________________________________________________ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge fM^^^feuAZj^yzet specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business a?WK^Ui^ 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 COUNTY Ordinance Codes, l3WS- ^anice Yeh Alj^ggr— date: 10/24/2025 State CA