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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNER / OPERATOR PHONE # 209 Exr. 932-0606 HOME or MAILING ADDRESS 4460 S. HIGHWAY 99 FRONTAGE RD. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES CHECK If BILLING ADDRESS® FACILITY NAME ZIP 95215 Si n SAN JOAQUIN COUNTY PUBLICH HEALTH SERVICES SITE ADDRESS E HAZELTON AVENUESTOCKTON EMPLOYEE #: DATE: 95205 1601 EMPLOYEE #: DATE: Date Service Completed (if already completed): Street Number Direction SERVICE CODE: Street Name Fee Amount: City Amount Paid Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Payment Date Payment Type Invoice # Street Number Street Name CITY STATE ZIP PHONE #1 Ex -r. APN # LAND USE APPLICATION # ( 209) 468-3400 155-050-060-000 PHONE #2 ExT• ( ) BOS DISTRICT LOCATION CODE CONTRACTOR /SERVICE REQUESTOR REQUESTOR RB ENVIRONMENTAL (Attention Melanie Garcia) CHECK if BILLING ADDRESS BUSINESS NAME RB ENVIRONMENTAL, INC. PHONE # 209 Exr. 932-0606 HOME or MAILING ADDRESS 4460 S. HIGHWAY 99 FRONTAGE RD. )CW1 � 209) 932-0610 CITY STOCKTON STATE CA ZIP 95215 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. also certify that I have prepared this application. and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE�nd FEDERAL,,IEIWS� APPLICANT'S SIGNATURE: k.- ��\i� X � DATE: 07/17/2023 PROPERTY/ BUSINESS OWNER El OPERATO / NA ❑ OTHER AUTHORIZED AGENT ❑ if APPLICANT is not the BILLING PARTY, proof o orization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS, U' CAA )CW1 �N 1+1 n Si n ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P 1 E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08