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SAN JOAQUv--OUNTv FNVIRONMENTAI, HEALTI.EPARTMEN'f Ise 1, 4 — : . <br /> SERVICE REQUEST Fuel Addilrve <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> Costco Wholesale,Attention: Licensing CHECK if BIL ss <br /> FACILITY NAME co LCO G as0 u rte, /". 10'1 1) <br /> SITE ADDRESS 2440 Daniels Street ? Manteca 95336 <br /> etre 1 Number Imctlon r.at Nam. City Zt. <br /> HOME Of MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 35005 Numb#rstmet Name <br /> CITY STATE ZIP <br /> Seattle Washin ton 98124 <br /> PHONE 01 EXT. APN# LAND USE APPLICATION$0 <br /> ( 425 ) 313-8100 241-530-01 N,IA <br /> PHONE#2 ErT. BOS DISTRICT LOCATION CODE <br /> 1 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inigues, Project Planner CNEexff BILLe4G Ao s <br /> BUSINESS NAME PHONE# E"' <br /> Barghausen Consulting Engineers, Inc. J 425 1 251-6222 <br /> HOME or MAILING ADDRESS FAx# <br /> 18215- 72nd Avenue South (425 ) 251-8782 <br /> CITY STATE ZIP <br /> Washin ton 98032 <br /> BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/Or project specitic FNVIRONNIFNTAL I-IFALTH DEPARTKIEN r hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this fornn. <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 /> C01 JN I V Ordinant c Cedes.S7OnflWY15,ST A TF.and F I lit IR .laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> I <br /> Paomwi v 181 SINESS OWN F.ROPERA'1 UN 13' %NAGI O'1 HER Ail i 110RIZF.D AGLV'r LN <br /> 11�11'ruc'-IA7 i.Y nal the 81i I I+'O'114Br)'I pro utitburiztrrion rn sikn is reyxired riele <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1. the owner or operalor of the property loc:lted a1 the <br /> above site address. hereby aulhorire the release: al' any and all results, geotechnical data and'or environmenialfsne assessment <br /> inloiniatioti 10 the SANJOAQUIN COUNTY LNVIRONMENTAI. 1117ALTII DFPART%1I-.NT as Soon as it is available and at the sante time it is <br /> provided ID me or my representative. J <br /> TYPE OF SEll REQUESTED: Tvek AddT+1Ve� Ur Vvieni- avid Tank :ynS-t1016LA-1 <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> NOV - 1 2012 <br /> SA.N JOAQUIN COUNTY <br /> E W RONMENTAL <br /> HEALT1l DEPARTMENT <br /> ACCEPTED BY: '— I r` EMPLOYEES: Vie,^}Cn/ DATE: <br /> ASSIGNED TO: EMPLOYEE#: 7 � �� - DATE: <br /> tau 7 I I I I Z_- <br /> Date Service Completed (if already Completed): SERVICE CODE: 0 A <br /> P I E: 2.303 <br /> Fee Amount: -t 1,4/ -retAtXj Amount Pald l / Payment Date It�� <br /> Payment Type invoice# Check# / U / !P S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />