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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 COUN I V Ordinance Codes, Standards, STATE and FEDERAL laws. (1. Ykl APPLICANT'S SIGNATURE: 'PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER El OTHER AUTHORIZED AGENT Member/Partner Title DATE: 5/10/2024 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. San Joaquin County Environmental Health Department Application Form A? Di 065 Faciiity Name -- 1,- - 7"-- . Grappa Investments LLC 60 ,‘„,,,,,_..., ),-... ).-._,L. L ( c Site Address 704 N Jack Tone Rd Suite A City Ripon State CA ZIP 95366 APN Supervisor District Type of Service Requested "Application for Operating Permit 0 Consultation 0 Change of Owner 0 Repairs or Remodel El Other Comments If mobile food truck or pumper truck License Plate Number VIN Contact Types required CI Billing Party "Facility Owner CI Facility Contact 'Property Owner CI Contractor CI Architect El Billing Party 6/Facility Owner CI Facility Contact VProperty Owner ID Contractor CI Architect First Name Gulbahar Last name If Saini contractor, indicate type and license number Address 704 N Jack Tone RD Suite A City State Ripon CA ZIP 95366 Phone (209)248-8424 Phone Email Jamba.acc@grappainv.com 0 Billing Party 0 Facility Owner El Facility Contact 0 Property Owner El Contractor 0 Architect First Name Last name If contractor,” r te type and license number Address City State ZIP Phone Phone Email \ 4% /1 0 Billing Party 0 Facility Owner 0 Facility Contact El Property Owner - ntrac o-t r V " 0 Architect itype and licenpriter_ First Name Last name cEIV1 Address City e ZIP MAY 23 2, Phone Phone Email SAN JOAQUIN CO HE- vIrcuNME ALTI NTAL I BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site ana/or prgjeCtANT ENT Accepted By 6.1.' : S - /144 i t t L) Assigned To 67,9 tzkti Li FA ID lot _7_ Date 1 1 4-1-7 Li 3 I , PE , -J, 23 /6 Fee . __ . 350 , Rtvg Drk, I2J- V 11 X31 INA V4//c ci 5404)24- 3