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❑ New Facility B Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> JKL Sunshine Corporation <br /> Site Address y �tH�te ��j21 rJ <br /> 6820 E Navone Road 9Vockton <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��7 <br /> Contractor ❑Architect <br /> required <br /> 9 Billing Party M 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@yahoos 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 licenAymber <br /> Address City State ZIP qq YY r <br /> ce, <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that a Si 01 �f ect <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busi as i�ient}FQI�pV <br /> form. ltkTtiQ �Nj,�^�n' <br /> 1 also certify that I have prepared this applic i and thaXtfork to rformed will be done in accordance with all SAN JOAQUIN COUNTY 0 i li l yI� <br /> Standards,STATE and FEDERAL laws. .4 <br /> APPLICANT'S SIGNATURE: DATE: r� �j b <br /> O PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT ce0 <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 SCO f f S. Fran Assigned To Linked FA 1D <br /> k �. <br /> Date i Z�LS PE 3��t Fee Record Number <br /> Payment <br /> Cash ❑Check# ❑Confirmation# Received By <br /> Rev 07/10/2024 <br />