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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# WS7ER�VICEE REQUEST# <br /> Liquor Store/Market � ! �� <br /> OWNER/OPERATOR <br /> Amar Dhillon CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> Country Club Market and Liquor <br /> SITE ADDRESS Country Club Blvd Stockton 95204 <br /> 1875 Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (209 )207-4582 123-182-160-000 <br /> PHONE#2 Exr. EMAIL BCIS DISTRICT LOCATION CODE <br /> ( ) amardeepdhillon20l3@gmail.com <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Zack Guebara CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> AG Renovation&Improvements <br /> ( 209)915-0577 <br /> HOME or MAILING ADDRESS FAX# <br /> 205 Seneca way ( ) <br /> CITY Lodi STATECAZip 95240 EMAIL zguebara@agbuildgroup,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 /> 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �&4 �l G�IC� DATE: 5/24/24 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is 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 provi d to n or my <br /> representative. A Y <br /> TYPE OF SERVICE REQUESTED: � yt 5 NECEIVEn <br /> COMMENTS: <br /> Plans have been submitted through gopost, project ID is: 9096 MAY 2 8 2024 <br /> Confirmation#for payment: 181954488 SAENVOIAQUIN COUNT <br /> RONMENT <br /> A L <br /> "The EHD he in asost reviewed the site t pthe lans and is processing it as Plan Check Only as follows:lans: HEALTH�EPARTt,EN <br /> Hold Building Permit pending submital of a Service Request and fee to the EHD for review and approval of a Food Facility Plan check" <br /> ACCEPTED BY: ,-v- c EMPLOYEE#: DATE: �a 7,.it- <br /> ASSIGNED ' <br /> TO: j?C I���/ EMPLOYEE#: DATE: <br /> �T 24 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: .� Amount Paid Lf F 00 Payment Date -T12--<.•2-'` <br /> Payment Type Invoice# Check# 8f Received'By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 I (l, <br />