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SAN JOAQUI?I COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street; Stockton,CA 95202 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Apartments FA0002729 .5 <br /> 1 <br /> o0�3.Si3 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> STOCKTON PHOENIX LIMITED <br /> FACILmNAME HAMPTON SQUARE APARTMENTS <br /> SITE ADDRESS 803 E Hammer Lane <br /> Street Number I Direction Street Name city Stockton ZI Code 95210 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 819 Street Name E Hammer Ln <br /> CITY STOCKTON STATE CA ZIP 95210 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209)957-5844 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR i SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# En. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY Proof of authorization t0 Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRO ENTALEALIU _ 1182 le and at the same time it is provided to me or <br /> my representative. F1AM <br /> TYPE OF SERVICE REQUESTED: Date Received �00 C-�.-C�l� ,Q.E�A-tQ ";'�E <br /> COMMENTS: PO# <br /> Batch# <br /> GL O (p <br /> Amount Paid <br /> Lcvi=lk/ <br /> ACCEPTED BY: EMPLOYEE#: /I)S --1 DATE: 8f48I!$ <br /> ASSIGNED TO: J@PWRW*6NKWM 1c0/L>F2-'t EMPLOYEE#: %94 (oL(3 DATE: 1W*W L^ (ett <br /> Date Service Completed (if already completed): SERVICE CODE: 522 PIE: 360[2 Y <br /> Fee Amount: $250.00 Amount Paid � p 0 Payment Date <br /> Payment Type VZInvoice# JWafft Check# G Lt ?Sl 9 2g Received By: <br /> AAA 1 SR FORM Golden Rod <br /> EHD 48-02-025 0 11 1i9 1 t � ( ) <br /> 07/17/08 <br /> 1 1 <br /> �''�' t1 'ilii: <br />