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! 4 <br /> S@RME REM1:S <br /> Type of Business or Property4 FACILfTY It}# SERVICE REQUEST# <br /> COSTCO GASOLINE FUELING FACT I <br /> oww/OPERATOR <br /> COSTCO WHOLESALE CORP. BLLMPAtl;rY <br /> FACtCRv NAuf <br /> COSTCO GASOLINE LOC. NO. <br /> Srrf AootrF$s <br /> 9fwl Nu'br 11 Dharon SCKalm! Typ! sua.a <br /> Mailing Address (If Different from Site Addresa) <br /> 999 LAKE DRIVE <br /> Crrr STATE jlp <br /> ISSAQUAH WA 98027 <br /> P;=--#1 dcr. APN# LAu0USEAPpuc non# <br /> (421 313-8100 <br /> PRONE 92 exr. BOS DtSTtticr '� _ • LOCATION CQ(IE : . <br /> CONTRACTORISERVICE MUESTOR <br /> R6nussssoR BnLwa PAM 0 <br /> COSTCO WHOLESALE CORP, c/o BARGHAUSEN CONSULTING ENGRS. INC. <br /> &sawu NAwE Prim# eat <br /> BARGHAUSEN CONSULTING ENGINEERS, INC. (4251 251-5222 7430 <br /> MALm Anomm FAX# <br /> 18215 72nd Ave South j4 2 54 251-8782 <br /> SrATI=. WA ZIP 98032 <br /> ACKNOWLEOGEMENT:I.me atrtdersgmW pmp wty or buahsaayt owner,operator or authorlwW ap at of same,admowledge to d aft vWbr pagrd spetiglc <br /> Ptiltat:'!•IFAt.Tft SEAviCES Eerrattksa;arru liEJu,TN pivassor+htsudydrupes sstodrbd+rBss Cita propct ar at�lvify w®br ts+�ed a rtr or ssar tsasitsaaa u ktatlfi`d an fait itfitL <br /> 1 also certify that I have prepared this app6radoo and that the work tn-§e_ppt£orr wd wd be done in a=rdana with an SAsr JoAmm Cocom 0ml7anoR CodWs,3kidrdL STATI incl <br /> FEDENALlava. <br /> + z <br /> AArtJCJ1KT saGaAn,xa: � J .J"' ��.. , —� DATE v � � - t-1,7Z <br /> PfwMrY!B MwEss OwHER id OPERATORI#MtuGEA a OTHER Avrro122fD ACExr a <br /> rAPKr-wrirrWhg{yjpad,,(ft*kw0"is&twFrMw-dsd riff* <br /> RU11 T"N To RELEME INFORM Ytsban apombir,I,Cse ownaroropefator of Cts pmperty bated at she above site address.hwaby whostaw asst atlYw of <br /> L# "rand dmulss,gootechnial dau ardor wtvimnmentallbi0t miessment I ft..*b b Car S►H ia�rx�s+Cxaxlt t Ptmuc HEutx S[Rv�s Et+wtt]es�6atAs MEAL 71�0enfI0M'asf fifCn <br /> ar ft Is&&able and at Cie same thaw f Is provided to ms ormy nipmsertift <br /> TYPdOF SERM REBGESM: <br /> Co�xrx: <br /> bapanoWs 3*mTusm COMTRACT 3 SMAMME: <br /> APpwmwr Ew toymt OAM <br /> Ana m rot Eupl om at DAM <br /> Data WAce Completed (if already completed): St7t1nCE CooE: P f E <br /> Fie Amoutat Amount paid Payment Date <br /> Paymas>tt Typal Invoice 9 Cheek# Received#Y- <br />