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form. <br />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 Oidinance Codes, <br />Standards, STATE and FEDERAL laws. (46 r APPLICANT'S SIGNATURE: <br />-1,'PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Member/Partner <br />Title <br />DATE: 5/10/2024 <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 />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name r <br />Grappa Investments LLC t-. g A <br />(..1' c.. <br />Site Address <br />704 N Jack Tone Rd Suite A <br />City State <br />Ripon CA <br />ZIP <br />95366 <br />APN Supervisor District <br />Type of Service <br />Requested <br />&Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party Facility Owner 0 Facility Contact crProperty Owner 0 Contractor ID Architect <br />CI Billing Party Pt/Facility Owner ID Facility Contact ck'Property Owner 0 Contractor 0 Architect <br />Fiist Name <br />GU] bahar <br />Last Caine <br />Saivai <br />If contractor, indicate type and license number <br />Address <br />704 N Jack Tone RD Suite A <br />City State <br />Ripon CA <br />ZIP <br />95366 <br />Phone <br />(209)248-8424 <br />Phone Email <br />Jamba.acc@grappainv.com <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner CI Contractor ID Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />NTY <br /> ^L <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site anorV8k , ced:aft ENT RE Z.Ti l 7P <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 />Accepted By n " Assigned To ) 9 iz-Avkij , Linked FA ID <br />Date <br />cc /7-3 /2 L1 <br />PE <br />172-- 3 <br />Fee . Record Number <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />PAY r11.5 2 First Name Last name i If contractor, indicate type and licenntei-E._ <br />i VI <br />Address City State ZIP <br />MAY 2 3 <br />Phone Phone Email <br />SAN JOAQUIN CO <br />19&(• Vi6bt 1g.1g - sp, ictfr( 2"131 N2t 4 032-Thg <br />P-e VvIC