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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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanci% <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: 1-4aAe <br />0 PROPERTY / BUSINESS OWNER M OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title .91 <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, <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEN <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />12/5/2024 DATE: <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Sizzling Wings, LLC Dba: Wingstop #50682 <br />Site Address <br />1342 E Yosemite Ave <br />City . manteca State cA <br />ZIP 95336 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation (XChange 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 X Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />KJ Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Kyla Last name Lapuaho If contractor, indicate type and license number <br />Address PO BOX 572408 Cit Y Murray State UT ZIP 95336 <br />V) -268-3400 Phone Email <br />Licensing@splat.com <br />ID Billing Party El Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Sizzling Wings, LLC <br />Last name If contractor, indicate type and license number <br />Address 348 E Winchester St citYMurray State <br />UT <br />ZIP <br />84107 <br />Phone <br />801-268-3400 P ine 120 <br />Email <br />Licensing@splat.com <br />O 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 I' t <br />I-- <br />Assigned To 1 . ..-- <br />10-- <br />Linked FA ID F. <br />R 00 21 <br />Date <br />i i_di Z /7 U <br />!PE <br />I Ao2 <br />Fee <br />i 11-2, 4t11,---- Record Number <br />siz.2440E68s- <br />)4,1)1i6C <br />Not5STKA S