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X24 S3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID' I SERVICE REQUEST# <br /> Multifamily Residential f Q ZLe <br /> OWNER/OPERATOR r, <br /> Thi A.. Mc(lici AssClciiies, T,P T-)BA Medici Arll,sl J,ofl.s CHECK If BILLINGADDRESS El <br /> FACILITY NAME Medici Artist Lofts c/o DKD Property Management Company <br /> SITE ADDRESS N Sutter Street Stockton 95202 <br /> 242 Street Number Direction Street Name I City Zip Code <br /> 255 <br /> rJMEorMAILINGADDRESS (If Different from Site Address) West Julian Street, Suite 301 <br /> Street Number Street Name <br /> CITY San Jose, STATE <br /> CA 6920202 <br /> PHONE#1 EXT_ APN# LAND USE APPLICATION# <br /> (209) 475-8542 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (707 )631-4683 cell 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Doretta Cramer CHECK If BILLINGAODRESS❑ <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 /> CITY San 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.FIEALTH 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,SCATS an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12/10/2020 <br /> PROPERTY/BUSINESSOwNER❑ OPERATOR/NIANAGER� OTIIERAUTHORIZEDACENT❑ 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, 1,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 the or my representative. <br /> TYPE OF SERVICE REQUESTED: Consultation PA/Y� T <br /> COMMENTS: f) c' Coe I /�_s 1 / ��` / O r� ��V�' D <br /> ��1 DEQ' 15 20 <br /> SAN JOAQUIN C UNTY <br /> E, RO MEN ,L <br /> ACCEPTED BY: EMPLOYEE#: o / , DATE: `Z / ENT <br /> ASSIGNED TO: EMPLOYEE#: DATE: f <br /> —1 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: CV& <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# :[ <br /> Check# P a 5 Z Received By: <br /> IL <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 1 1/1 712 003 <br />