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H New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name River Islands High School Cafeteria 16601 Loganberry WaySite Address City State ZIPLathropCA 95330 Consultation Change of Owner Repairs or Remodel W Other License Plate Number VIN Billing Party Facility Owner Property Owner Contractor Architect Billing Party Facility Owner Facility Contact Property Owner Contractor 8 Architect Wohle If contractor, indicate type and license numberLast name State ZIP 222 Central Court Stockton CA 95204 ArchitectKI Facility Contact Property Owner Contractor Billing Party Facility Owner If contractor, indicate type and license number Phone Property Owner Contractor Facility Owner Facility Contact Billing Party Last nameFirst Name StateCityAddress EmailPhonePhone 02-24-2026DATE: ARCHITECT (X OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER Title Linked FA IDAssigned ToAccepted By Vidal Pedraza Kadeanne Linhares FeePEDate2/24/2026 5371601 Check# Cash 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. City Tracy Payment Received By APN 213-620-11 First Name Rechelle Email rpearlman@bantasd.org ZIP 95304 /T D Last name Pearlman State CA Record Number AY2-(fOi02>^ 216306514 ^Confirmation tl Address 22375 EI_Rancho rd. Phone 209-229-4651 Supervisor District _ _Banta Application for Operating Permit Type of Service Requested Comments NEW High School Cafeteria If mobile food truck or pumper truck Phone Phone 209-943-0405 First Name Eric *Alternate contact: Jesus Valdez Address | City Email ewohle@ldapartners.com *Alternate: ivaldez@ldapartners.com I Facility Contact If contractor, indicate type and ...T*/5 aa ___________ Sggg? BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or profMAffi^^- specific ENVIRONMENTAL HEALTH DEPARTMENT 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; ;