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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTRIWARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />Retail Gasoline Station <br />OWNER I OPERATOR <br />CHECK if BILLING ADDRESS❑ <br />Costco wholesale Corporation <br />FACILITY NAME <br />Z <br />Costco Gasoline Station <br />SITEADDRESS/j 6 vay <br />and Dane s reet Manteca 95330 <br />r Nks t umber Direction <br />Street Name Cit Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />999 Lake Drive <br />Street Number Street Name <br />CITY <br />STATE ZIP <br />Issaquah <br />VIA 98027 <br />PHONE#1 EXT. APN # <br />LAND USE APPLICATION # <br />( 425 ) 313-8100 <br />PHONE#Z EXT. <br />BOS DISTRICT LOCATION CODE <br />CONTRACTORI�SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS El <br />David E. Painter <br />BUSINESS NAME PHONE # ExT. <br />Barghausen Consulting Engineers, Inc. 425 251-6222 <br />HOME or MAILING ADDRESS FAx # <br />18215 - 72nd Avenue South (425) 251-8782 <br />CITY STATE ZIP <br />Kent WA 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 a 'cation and that the wor performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards STAT and FED a <br />APPLICANT'S SIGNATURE: c DATE: ZZ007 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑x Assistant Planner <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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; Underground Storage Tank Installation Permit Application Review <br />COMMENTS: <br />COMMENTS: PA 1/ <br />R -coVED <br />SEP 2 7 2007 <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Fee Amount: 155 O • i�` Amount Paid � <br />Payment Type <br />Invoice # <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />EMPLOYEE #: �~ DATE• 21 G <br />EMPLOYEE#: Z -Ce% V DATE: <br />SERVICE CODE: a ( Q 1 E: 2 - <br />Payment <br />Payment Date.,III I b' <br />Check # <br />Received By: <br />EHD 48-02025 13107.003.pdf SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />