Laserfiche WebLink
IX New Facility ❑ Existing 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 Z 9 9 <br /> Type of Service Q Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> CCL for Distributor - Wholesale Type II - Warehouse Transport <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types Billing Party Facility Owner IIR Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party X Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> L L k'ISA in a Co 0 r- 4,1710 17 <br /> Address a� City State � ZIP <br /> W- 04 a �Zq! <br /> hone Phone Email <br /> (p$O tfoo8'- Z ZZ /u.,7-4/17 ZOO Z cc,4 oo. Corn <br /> XBilling Party ❑Facility Owner IXFacility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> C'tien <br /> Address Po BMX City 01 n State (�'/� ZIP �SZOS <br /> Phone Phone Email Q <br /> 5� 8�8'8" /22 2 /u•r b Zo 0 Z u 00. Gorr <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: j�� <br /> ElPROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER El OTHER AUTHORIZED AGENT •\�^r^ ��1/� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title y <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site ad ess,h�rby/a�h°°��qthe <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY EN�TAL HEAZF 4 <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. F QV/l�l <br /> 414 <br /> Accepted By Q �� 4^ Assigned T Linked FA ID <br /> S 9 9 anin'r a_ o00 )-7 avr <br /> Date / PE � ,/�0 Fe#2 � �,! � � Record Number �' <br /> Z <br /> ,ten Payment <br /> Cash -A21I ❑Check# ❑Confirmation# Received By <br /> If—10 Rev 07/10/2024 111 <br />