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E New Facility San Joaquin County Environmental Health Department Application Form Supervisor District □ Consultation □ Change of Owner □ Repairs or Remodel License Plate Number VIN □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect □ Facility Owner □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number Address City State ZIPLos Angeles CA 900365858 Wilshire Blvd. # 200 Phone □ Architect□ Facility Contact Ki Property Owner □ Contractor□ Billing Party □ Facility Owner If contractor, indicate type and license numberLast nameFirst Name PattersonScot State ZIPCityAddress 95370SonoraCA133 Old Wards Ferry Rd., Ste G Phone □ Architect□ Facility Contact □ Property Owner□ Billing Party State ZIPCityAddress EmailPhone 10/3/2024DATE: □ PROPERTY / BUSINESS OWNER Linked FA IDAssigned To I \ □ Check# Rev 07/10/2024 Contact Types required 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. IX Application for Operating Permit Email entitlements@valerioinc.com Email scot@calgolddevelopment.com City Manteca Phone 323.954.8996 State CA Phone 209-533-3333 ZIP 95337 ^Cipacility Contact Type of Service Requested Comments Facility Name Starbucks Site Address SWC S. Main St & W. Atherton Dr. (address not yet assigned) APN 224-021-30 & 47 K Other Tenant Improvement Starbucks drive-through tenant improvement in shell building by landlord. No cooking onsite, kO If mobile food truck or pumper truck Planner Title lx Contractor TBD If contractor, indicate type and license number ^Tacility Owner Record Number _______________ ^Confirmation# 2- First Name a vcro? D Date □ Cash Last name . . w v I BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPART MENT 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. /*■ ./ /> / / APPLICANT'S SIGNATURE: □ OPERATOR / MANAGER K OTHER AUTHORIZED AGENT ® Billing Party Agent First Name Emily Last name Gustafson Accepted By PE Fee $ 1(^00 Payment Received Ry {srl (y