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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail-- Prepackged Only, No Food Prep <br />FACILITY ID # <br />FA0010801 <br />SERVICE REQUEST # <br />S ROO 8 -3-9 53 <br />OWNER/OPERATOR <br />CHECK if BILLING ADDRESS . Dolgen California, LLC <br />FACILITY NAME Dollar General Store #25626 (formerly Store #14130) <br />SITE ADDRESS 4115 <br />Street Number <br />N <br />Direction <br />El Dorado St <br />Street Name <br />Stockton <br />City <br />95204 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 100 <br />Street Number <br />Mission Ridge <br />Street Name <br />CITY STATE ZIP Goodlettsville TN 37072 <br />PHONE #1 EXT. <br />(615) 855-4000 <br />APN # <br />115-115-050-000 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL <br />tax-beerandwinelicense@dollargeneral.com <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />John Hunter CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Ameritech Facility Services, LLC <br />PHONE # Ext. <br />(972) 672-5225 <br />HOME or MAILING ADDRESS <br />1500 Airport Drive, Suite 200 <br />FAX # <br />( ) N/A <br />CITY Ball Ground STATE GA ZIP 30107 EMAIL._ uGRemodel@ameritechfs.com <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or activity <br />will be billed to me or my business as identified on this 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 <br />COUNTY Ordinance Codes, Standards, STATE nd FEDERAL laws. <br />4 <br />/ ,4 - <br />APPLICANT'S SIGNATURE: -fy,b/.., Michael Burdette DATE: 4 /19/24 <br />Senior Licensing Specialist PROPERTY! BUSINESS OWNER 0 OPERATOR ; MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT /S not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my <br />representative. <br />TYPE OF SERVICE REQUESTED: Inspection to Reinstate Food Permit PAY 4 <br />COMMENTS: RE.CE7 t <br />A PR 2 2 2 <br />SAN J0 4 ,, , <br />ENviR <br />, <br />o%1110N CC <br />ACCEPTED BY: SIJ.,j EMPLOYEE #: Cl t'S' DATE: L-1-4-ti.714/4 1 . 7-4 <br />ASSIGNED TO: LA.../1 C, la EMPLOYEE #: OM Ct./ DATE: L41,)_?...../ a_14 <br />Date Service Completed (if already completed): SERVICE CODE: (-..:.. J.,„ i P I E: <br />Fee Amount: 4) I 16)2---- Amount Paid e.,, 1 (6, ,?.-- Payment Date q 1 1 of 01J7-_Li <br />Payment Type Cver IV Invoice # Check # ig 6- ,OrDTS-8 -=2_ Received By: <br />EHD 48-02-025 <br /> CzY1--wffilvil <br />SR FORM (Golden Rod) <br />03/22/23 <br />K, 537LIClq <br />NT ET) <br />24 <br />UNTy <br />ENT