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SAN JOAQ COUNTY ENVIRONMENTAL HEAL,. DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />COMMERCIAL <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />J & D AUTO CHECK If <br />ra <br />BILLING ADDRESS 50 <br />FACILITY NAME J & D AUTO <br />SITE ADDRESS 1011 <br />Street Number <br />S <br />Direction <br />CHEROKEE LANE <br />Street Name <br />LODI <br />City <br />95240 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />047-400-07 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />ERIN ROTTACKER CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />ADVANCED GEOENVIRONMENTAL, INC ( <br />PHONE # EXT. <br />)209-467-1006 <br />HOME Or MAILING ADDRESS <br />837 SHAW ROAD <br />FAX # <br />( ) <br />ciry STOCKTON STATE CA zip 95215 <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 <br />or activity 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, ST E and FEDERAL laws. <br />APPLICANT'S SIGNATURE: LAP)/ly d t o rio ca DATE: <br /> <br />PROPERTY / BUSINESS OWNEREI 0 ERATOR / MANAGER OTHER At1THORIZED AGENT 0 f3ust Marl etiedC-r- <br />//APPLICANT is not the MUIR; 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentalisite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P/ E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)