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□ Existing Facility San Joaquin County Environmental Health Department Application Form Pt2- Supervisor District □ Consultation □ Change of Owner □ Repairs or Remodel □ Other □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect 0 Facility Contact □ Property Owner □ Contractor □ Architect If contractor. Indicate type and license number ZIP 94513 □ Facility Owner □ Facility Contact □ Property Owner □ Contractor□ Billing Party □ Architect If contractor. Indicate type and license numberFirst Name Last name Address City State ZIP Phone Phone Email □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party First Name Last name Address City State Phone EmailPhone DATE: Cl OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT□ PROPERTY / BUSINESS OWNER ■Ownat. Title linked FA IDAssigned ToAccepted By iV>□ Confirmation # 4^Rev 07/10/2024 If mobile food truck or pumper truck 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 envlronmental/slte 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. ,W- . I PE [^Facility Owner Martha Bergquist Q Application for Operating Permit Email letibergquist@gmail.cor i Last name Bergquist VIN 53BLTEA24ET003640 City Pittsburg City Brentwood License Plate Number 4wc6122 ZIP 94565 Payment Received By State Ca State CA Type of Service Requested Mpp Comments Facility Name ________Hula Hawaiian Shave Ice Site Address 2173 Martin St APN 2 I? $1^ SumnvywuvA 'Of- Phone □ Check# Contact Types required D Billing Party Martha Bergquist First Name Martha Address 681 Phone (925) 382-8900 If contractor. In number -----RECE/vEd------- JQAgUi^ GQHiu rv —____ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed tntified 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. Martha Bergquist APPLICANT'S SIGNATURE: wksi.i.p un mao, sf New Facility w □ Cash Inly 6th, 2025