Laserfiche WebLink
San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Jamba Juice <br />Site Address 704 N Jack Tone Road <br />APN Supervisor District <br />X Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />El Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />Phone Email <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />StateAddressCity ZIP <br />Phone EmailPhone <br />□ Property Owner □ Contractor □ Architect□ Facility Owner □ Facility Contact□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br />11-20-2025DATE: <br />X OPERATOR / MANAGERX PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT <br />Title <br />Assigned ToAccepted By <br />□ Confirmation H□ Check it <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />Last name <br />Singh <br />ZIP <br />92024 <br />City <br />Encinitas <br />State <br />CA <br />_________ <br />First Name <br />Chanchai <br />Address <br />1467 Paseo De Las Flores <br />Phone <br />Type of Service <br />Requested <br />Comments <br />State <br />CA <br />City <br />Ripon <br />□ Application for <br />Operating Permit <br />License Plate Number (/ fc=^ 7n / <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required NOV 2 5 2025 <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 ENVlRONlwAJlWQAQUIN CC UNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.ENVIRONMENTAL <br />Date / z- ) PE / /'I <br />///W2S <br />□ Cash <br />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 Ordinance Codes, <br />Standards, STATE and FEDERAL laws. . -1190 909^ PAYMENT <br />APPLICANT’S SIGNATURE: _________( DATE: 1 1-20-21)25____________ ,,,UI 1 1 <br />DECEIVED <br />ZIP <br />95366 <br />ENVIRONMENTAL <br />health derarj>ient <br />lOv t <br />Record Number <br />III 316 [ Received By I <br />uS) Ct ft: lll25lZ^