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ew Facility XExisting Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> JKL Sunshine Corporation <br /> Site Address City State ZIP <br /> 6820 E. Navone Rd. Stockton CA 95220 <br /> APN Supervisor District <br /> 101-120-31 4/99 <br /> Type of Service Q Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> CCL for Cultivator Medium Indoor <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck <br /> Contact Types R]Billing Party Facility Owner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party f-Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name / � � CoL�name If contractor,indicate type and license number <br /> Address V� ^�^ AlaV017� r�J2 //. City �G StateC� ZIP gs�s <br /> hone v�r ICJ Phone Email <br /> ZZ G G /&t`Y►b/ o a.C0,01 <br /> Billing Party ❑Facility Owner RTacility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Nam Last nam If contractor,indicate type and license number <br /> Address J;�16 >OX Sq/Z City State A,� ZIP9 <br /> Pho Pone Email („� <br /> --�ZZ-Z /116*1 - n 7ElO Z •o. 0.n <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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. <br /> APPLICANT'S SIGNATURE: DATE: c <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> �+� 1) <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title pp�� <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,101010 altl/,/n the <br /> �Oq <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR§AWENTAL HERLTAiS <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By Assigned To �/ Linked FA D_ pEp"T�eN <br /> Date PE / Fe (� Record Number <br /> r io Z — fJP2' CLI' +2 ?P z�{ <br /> Payment <br /> Cash ❑Check# ❑Confirmation# Received By <br /> Rev 07/10/2024 <br />