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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Retrofit <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Costco Gasoline <br /> OWNER/OPERATOR <br /> Costco Wholesale,Attention: Licensing CHECK If BILLING ADDRESS❑ <br /> FACILITY NANE <br /> Costco Gasoline(LOC.No. 1031) <br /> SITE ADDRESS 2440 Daniels Street Manteca 95336 <br /> Street Number Directim Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 35005 Street Number Street Name <br /> CITY STATE ZIP <br /> Seattle Washington 98124 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 425 1313-8100 241-530-01 N/A <br /> PHONEY Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK D BILLING <br /> Alexia Inigues, Project Planner <br /> BUSINESS NAME PHONE# T <br /> Barghausen Consulting Engineers, Inc. 425 251-6222 <br /> HOME Or MAILING ADDRESS FAX# <br /> 18215-72nd Avenue South (425 ) 251-8782 <br /> CITY KentWashing on ZIP 98032 <br /> BII LING 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 FED 3_ laws. �J" <br /> APPLICANT'S SIGNATURE: DATE: v <br /> PROPERTY/BUSINESS OwNER❑ OPERATOR/ 'AG <br /> OT HER AUTHORIZED AGENT O Di actor 0l Real Estate Development <br /> IfAPPL TCANT is n a t theBmUNGPAaYY pr jof a horizadoa to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATIO : When pplicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of an 1 results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUW COUNTY ENvraoNMENTAL 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: Retrofit Existing Tanks for Fuel Additive Installation <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE If: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 198 PIE:2308 <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 />