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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Businesl or Property FACILITY ID# SERVICE REQUEST# Right of way Unocal#6981; RWQCB Case#390204, OWNER/OPERATOR 76PP#351515 City of Stockton - Encroachment Permit No. 17-0479 CHECK If BILLING ADDRESS❑ FACILITY NAME Pacific Avenue SITE ADDRESS 95207 SITE Block Pacific Avenue Stockton Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) City of Stockton Permit Center 345 Street Number N.El Dorado Street Street Name CITY �T Stockton TTE ZIP 95202 PHONE#1 EXT. APN# LAND USE APPLICATION# ( 612) 761-635 N/A-Right of Way PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( 707 ) 843.6032 (Jennifer Granbor Arcadis U.S. Inc. Consultant CONTRACTOR / SERVICE REQUESTOR REQUESTOR Katherine Brandt13CHECK If BILLING ADDRESS PHO EXT, BUSINESS NAME Arcadis U.S., Inc. ( 707)843-6032 (Jennifer Granb(rg) HOME or MAILING AD E$g FAX# 10gmrth Ranch Road, Suite 329 ( )jennifer.granborg@arcadis.com CITY STATE ZIP San qfael CA 94903 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. 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 COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: Li`, . ,:'' 1 DATE: 04/03/17 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Professional Geologist If APPLICANT is not the BILLING PARTY,proof of authorization 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: ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: P/E: Fee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003