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5i New Facility 0 Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Destiny's Sweet Treats Site Address 2101 west Tokay st City lodi State Ca ZIP 95242 APN Supervisor District Type of Service Requested IlApplication for Operating Permit 0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other Comments PAYME RECFn If mobile food truck or pumper truck License Plate Number VIN 111 1 7 Contact Types required 0 Billing Party CkFacIlity Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Arc hitettN JoAcwIN C ENVIRONMEt HEALTH DEPAR o Billing Party EkFacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Destiny Last name B urgess If contractor, indicate type and license number Address 2101 West Tokay St City Lodi State Ca ZIP 95242 Phone (209)371-7864 Phone Email Destinybaptista@gmail.com 0 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 0 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 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 by pdller ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, MIMS. V;rifled Standards, STATE and FEDERAL laws. 2Degit butje3.3 vs ,,/tn/2024 07/10/24 APPLICANT'S SIGNATURE: DATE: a PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 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. Accepted By ,(--- I Assigned To 7...— 0 , f..- l. I • 7.- Linked FA ID Fikri-D am & 0 Date It PE L C g Fee Si I g Record Number P il azt 704 oei 1469ii PAA-1<- )0 4f_ Livc7,012- NT ED 2024 UNTY TAL RENT