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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Multifamily Residential <br /> OWNER/OPERATOR <br /> DFA Medici Associates, LP DBA Medici Artist Lofts CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Medici Artist Lofts c/o DKD Property Management Company <br /> SITE 4A DRESS N Sutter Street Stockton 95202 <br /> Street Number Direction Street Name I Citv Zip Code <br /> OMErJor MAILING ADDRESS (If Different from Site Address) West Julian Street, Suite 301 <br /> Street Number Street Name <br /> CITY San Jose, STATE <br /> A18202 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 475-8542 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> (707 ) 631-4683 cell <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Doretta Cramer CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME DKD Property Management Company PHONE# EXT. <br /> 408 297-7849 108 <br /> HOME or MAILING ADDRESS FAX# <br /> 255 West Julian Street Suite 301 ( 408) 297-4155 <br /> CITYSan Jos STATE CA ZIP 95110 <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,STATE an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12/10/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGERX OTHER AUTHORIZED AGENT❑ Director of Property Management <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site 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: Consultation <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />