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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 y t to I <br /> 6820 E Navone Road IOCkton 215 <br /> APN Supervisor District <br /> 101-120-31 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ®Other <br /> Requested Operating Permit <br /> Comments <br /> PR2400426 and PR2400427 Renewal <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ®Billing Party M Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> B Billing Party ®Facility Owner ❑Facility Contact ❑Property 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 type and licenW4nber <br /> r7o <br /> Address City State ZIP <br /> - I <br /> ------ -----jEFCF;v <br /> Phone Phone Email D <br /> OCT <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that a Si (�r et <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busi as I�Jentx- <br /> form. WAS 7*I .0 EIyT�J�7Y <br /> I also certify that 1 have prepared this applic and that t ork to rformed will be done in accordance with all SAN JOAQUIN COUNTY Or�Tiifdnit I <br /> Standards,STATE and FEDERAL laws. A <br /> APPLICANT'S SIGNATURE: DATE: <br /> —7� <br /> 0 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 Seoff dran <br /> Assigned To Linked FA ID <br /> S. k Ca. <br /> Date PE 3 �,�f Fee$ <br /> ?y`/ 3 0� Record Number <br /> S(Z25 m/5 3 Z. <br /> Payment <br /> Cash ❑Check# ❑Confirmation# Received By <br /> Rev 07/10/2024 <br />