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SAN JOAQUI 0touwY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Fuel Additive <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Costco Gasoline � 66 6 � <br /> OWNER/OPERATOR <br /> t� `� <br /> Costco Wholesale,Attention: Licensing CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Costco Gasoline(Loc. No. 1031) <br /> SITE ADDRESS 2440 Daniels Street Manteca 95336 <br /> Street Numhar I Di,e tion I Sbeet N a city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 35005 SI Number Street Name <br /> CITY STATE ZIP <br /> Seattle Washington 96124 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> 1 425 ) 313-8100 241-530-01 N/A <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inigues,Project Planner CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> Barghausen Consulting Engineers, Inc. 425 251-6222 <br /> HOME or MAILING ADDRESS FAX# <br /> 18215-72nd Avenue South (425 ) 251-8782 <br /> CITY KentW SVT ton ZIP 98032 <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 and FSO aws. <br /> APPLICANT'S SIGNATURE: DATE: �L <br /> PROPERTY/BUSINEss OwNER❑ OPERATOR/ AGER OTHER -TPHORaED AGENT R1 Director of heal Estate Development <br /> If APPLICANT is not the BILLING PAR Tr,D f of a orization to sign is required Title <br /> AUTHORIZATION TO RELEASE UVFORMATIOH:Y11i en 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 me or my representative. <br /> TYPE OF SERVICE REQUESTED:Fuel Additive Equipment and Tank Installation <br /> COMMENTS: ? F , I - <br /> .-,� Fit_ Yi <br /> ENVY ONPvrI-NT:,L HE}ii}1 <br /> ACCEPTED BY: N_In JiMlir,'�I�?,t,;_t:✓{1Li}1 EMPLOYEE#: --..•• J._HVt, `DATE: <br /> r r — <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 031 PIE:E'2303 <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 11117/2003 <br />