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SAN JOAQIJ COLIN'I'1' ENVIRONMEN'I'Al. 11EALThwOEPART\IENT h<'c AI;oi <br /> SERVICE REQUEST Retrofit <br /> Type of Business or Property FACILITY ID# SERVICE REQUESTI! <br /> �, _>i�CL') (L(c6 'el`r <br /> OWNER 1 OPERATOR <br /> Costco Wholesale.Attention: Licensing CHECK it NG <br /> FACILITY NAME <br /> CflSFc.L3 Gaso�('ne, �Lor✓. No- Io3I) <br /> SITE ADDRESS 2440 Daniels Street Manteca 95336 <br /> r Number it r I <br /> HOME Of MAILING ADDRESS (N Different from Site Address) <br /> P.O. Box 3500 s N <br /> CITY STATE ZIP <br /> Seattle Washiniction 98124 <br /> PHONE 01 EXT. APN# LAND USE APPLICATION# <br /> If425 ) 313-8100 241-530-01 MIA <br /> PHONE#2 E.T. ROS DISTRICT LOCATION CODE <br /> I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inlgues, Project Planner CHECK 0BILLING <br /> BUSINESS NAME PHONE# <br /> Barghausen Consulting Engineers, Inc. 425 1 251-6222 <br /> HOME or MAILING ADDRESS FAx# <br /> 18215- 72nd Avenue South (425 ) 251 8782 <br /> CITY <br /> Wa hiin ton ZIP 98032 <br /> BILLING ACKNOWLEDGEMENT: I. Ito undersigned property or business owner. Operator or authorized agent of same. <br /> acknowledge that all site mld!or project specific FSVIRONNIFNTAL 11FALT11 DEPARTMENT hourly charges associated \vide this pniiect <br /> or ac(i\ity will be billet/to me or my business as identified on(his form. <br /> I also certify that I have prepared this application and (hat the work to be performed will be done in aCCOrdaIIOC With all SAN JO.AQUIN <br /> ('I II IN I Y f)rdiuoury C'udre..SOUHlnrdc,S 1 A fh and Fi ut RAI. IaWs. <br /> APPLICANT'S SIGNATURE: _ DATE: <br /> PROPER I\/BI SINESSOWNER® OPERAI OR I MAN,\GERI] 01 In.R At,I lonuzvo AGENT❑ <br /> !(;trrlu',cvrisarHrltrRu.r/\'r;!'tH7r,prnaJ'uf-N mrizatiIll sign isrequired Till'. <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1. the Owner or Operator of the properly located al the <br /> above site address. herchy authorize the release of any and all results, geotechnical data andhlr enxironmentaltsile assessment <br /> III let Illat ion 10 the SAN JOAQI.I IN COON 1"\- LN\'I ROHM ENTNI. III:AI TH DPPA R1 N1 ENT as Soon as it is ava itable and at the sante time ii is <br /> pru\ided hl me or my represcnwtivcr. -rte r <br /> TYPE OF SERVICE REQUESTED: lZeJ O(Y+ "EX t'S+17\ 10-Aks -rw 'Fue l Ad&L+tyc— Tvi$ t <br /> COMMENTS: RECEI% <br /> NAV _ 1 2012 <br /> `-�`"ERONMEI�T <br /> TM94T <br /> NSP{OFP�R <br /> ACCEPTED BY: EMPLOYEE#f DATE: jI I I Z <br /> ASSIGNED TO: --��' _ EMPLOYEE DATE: <br /> Date Service Completed (if alraadycompleted): SERVICE CODE: t Lt8 PIE: Z?JO <br /> Fee Amount: '�Oji" r, -i Amount Paid 3 r Payment Date <br /> Payment Type Involce# Check# '7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />