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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 th. . dication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL la <br />APPLICANT'S SIGNATURE: <br />RPROPERTY / BUSINESS OWNER U OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <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 />DATE: <br />U New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />First Toast <br />Site Address <br />217 N. School St Ste 3 <br />City <br />lodi <br />State <br />CA <br />ZIP <br />95240 <br />PAYAlp .... REepn , <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation Change of Owner 0 Repairs or Remodel 0 Other <br />Comments NOV 01 a s AN j04 „. . <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />L., ENVIR?;lq„ULN CO <br />IlEALTH <br />Contact Types 0 Billing Party <br />required <br />0 Facility Owner 0 Facility Contact DI Property Owner DI Contractor DI Architect <br />EXBilling Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Armando <br />Last name <br />Rodriguez <br />If contractor, indicate type and license number <br />Address10169 Van Parker Ln City <br />Galt <br />State Ca ZIP <br />95632 <br />Phone 209-954-8510 Phone <br />EmliOdifirsttoast@gmail.com <br />0 Billing Party 0 Facility Owner 0 Facility Contact DI Property Owner 0 Contractor D Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Accepted By ,,..-, <br />C_ot_ArP,A.t& cc, <br />Assigned To D %. <br />i LA ( 7- <br />Linked FA ID FA- e 9 io2• *--.C° <br />Date PE Fee Record Number <br />SRA (DCD 01'5 <br />0 Cash 0 Check # AConfirmation # Icf 07257 -5---- <br />Payment dilr <br />Received By <br />Rev 07/10/2024 Igo <br />NT <br />ED <br />24 <br />NTy <br />RNT