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Ducusign Envelope ID: 98975881-2425-4350-9EB5-4E7052C56D2C ^k^New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />DAISO <br />Site Address City State ZIP5308 Pacific Ave.Stockton 95207CA <br />APN Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel <br />License Plate Number VIN <br />0 Billing Party KI Facility Owner [X Facility Contact □ Property Owner □ Contractor <br />[5 Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />If contractor, indicate type and license numberFirst Name Last nameDAISO USA LLC <br />Address City State ZIPAnaheim1900 S State College Blvd Suite 500 92806CA <br />Phone EmailPhone2064127781 mariela.fi )res@daiso-usa.con <br />□ Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberLast nameFirst Name DAISO USA LLC <br />Address City ZIP1900 S State College Blvd Suite 500 Anahei m 92806 <br />Phone Email accountspa/able@daiso-usa.cam <br />& Facility Contact □ Contractor □ Architect□ Property Owner□ Billing Party □ Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name FloresMari el a <br />City ZIP <br />Anaheim 92806 <br />EmailPhone <br />11/5/2025DATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />FeeDal <br />□ Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Kl Application for <br />Operating Permit <br />Payment <br />Received By <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 apokeattatasiclriduttythe 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: _______ <br />^Confirmation # <br />0 Facility Owner <br />Type of Service <br />Requested <br />Comments <br />aiimzp <br />-----8BCAD8E41B2849A.. <br />*□ OPERATOR / MANAGER <br />________ <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 />Il|PE IbQTs <br />□ Check # <br />State <br />CA <br />State <br />CA <br />Address <br />1900 S State College Blvd Suite 500 <br />Phone <br />D Wment <br />~ Nov 0 6 2025 <br />□ Architect <br />Phone <br />2064127781