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❑ New Facility 8 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> JKL Sunshine Corporation <br /> Site Address 6820 E Navone Road §4y Stte �I215 <br /> iockton t�/'1 <br /> APN Supervisor District <br /> 101-120-31 <br /> Type of Service ❑Application for Tconsultation ❑Change of Owner ❑Repairs or Remodel R Other <br /> Requested Operating Permit <br /> Comments <br /> PR2400426 and PR2400427 Renewal U�`ti r VAA r' vt <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types 8 Billing Party B Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> 8 Billing Party 8 Facility Owner ❑Facility Contact ❑Pro perty Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Kevin Chen <br /> Address City State ZIP <br /> 6820 E Navone Road Stockton CA 95215 <br /> Phone Phone Email <br /> 415-999-3577 kcplumbing2002@yahoo.cc m <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 Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate typ e s <br /> Address City State ��IP Fo <br /> JVA <br /> Phone Phone Email H FV 41 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge tha * j�ct <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i F n this <br /> form. �IT <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: R"Vth-(Jun 8,202615:26:08PDT) DATE: OA/nR/` A <br /> 8 PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT ceo <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <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 ENVIRONMENTAL HEALTH <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 ID <br /> Dat PE Fee Recor Qr O 4^ c <br /> Payment <br /> ❑Cash k# Confirmation# � �r` 1 Received By <br /> Rev 07/10/2024 <br />