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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 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: El PROPERTY / BUSINESS OWNER 7/3/24 0 OPERATOR / MANAGER El OTHER AUTHORIZED AGENT owner Title 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. DATE: Li New Facility 0 Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Sugar meets Spice Site Address 367 N. Union Rd. Apt.# 116 City Manteca State Ca ZIP 95337 APN Supervisor District Type of Service Requested 0 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 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner CI Contractor 0 Architect 0 Billing Party X 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Patricia Last name Morales If contractor, indicate type and license number Address 443 Benjamin Place City Manteca State CA ZIP 95337 Phone (209) 499-4606 Phone Email lapm79@yahoo.com El Billing Party 0 Facility Owner 0 Facility Contact El Property Owner El Contractor El Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email El Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email Accepted By Vidal Pedraza To Assign ed Gehane Famy Linked FA ID Date 7-3-24 PE 1602 Fee Record Number 4P2A-(0)C, tb Rev 06/12/2024 W2,40A5V)