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Date run 12/13/2018 3:31:56F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/13/2018 <br /> Record Selection Criteria: Facility ID FA0000700 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : 624-13-6907 <br /> Owner ID OW0005441 New Owner ID : <br /> Owner Name SUN RAY LLC GURINDER SINGH SAHOTA DBA <br /> Owner DBA LAKEWOOD LIQUORS LAKEWOOD LIQUORS <br /> Owner Address 34215 RED CEDAR CT 8765 HERITAGE HILL DR <br /> UNION CITY, CA 94587 ELK GROVE,CA,95624 <br /> Home Phone 408-649-8231 9166672786 <br /> Work/Business Phone 209-368-8956 2093688956 <br /> Mailing Address 34215 RED CEDAR CT 215 LAKEWOOD MALL <br /> UNION CITY, CA 94587 LODI,CA 95242 <br /> Care of KAHLON, KIRPAL GURINDER SINGH SAHOTA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0000700 <br /> Facility Name LAKEWOOD LIQUORS LAKEWOOD LIQUORS <br /> Location 215 LAKEWOOD MALL 215 LAKEWOOD MALL <br /> LODI, CA 95242 LODI,CA95242 <br /> Phone 209-368-8956 2093688956 <br /> Mailing Address 34215 RED CEDAR CT 215 LAKEWOOD MALL <br /> UNION CITY, CA 94587 LODI,CA95242 <br /> Care of KAHLON, KIRPAL GURINDER SINGH SAHOTA <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 03534009 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KAHLON, KIRPAL GURINDER SINGH SAHOTA <br /> Title OWNER OWNER <br /> Day Phone 408-649-8231 9166672786 <br /> Night Phone 408-649-8231 9166672786 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0008353 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facilit Account <br /> Account Name LAKEWOOD LIQUORS (Circle One) <br /> Account Balance as of 12/13/2018: $250.00 <br /> (Circle One) <br /> Transferto J Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1615-RETAIL MKT 301-2000 SQ FT(PREPKGD/LTD PR PRO160325 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and Stale and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: jJ �'rY�`� ' '�Y Date 01 / 22 / 201e <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / ! Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />