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,%. `..►, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT BCE #14573 <br /> SERVICE REQUEST <br /> Type of Business or Properly # SERVICE REQUEST# <br /> EE2! <br /> Costco Gasoline <br /> OWNER I OPERATOR CHECKH BILLING ADDRESS❑ <br /> COSTCO WHOLESALE <br /> FACILITY NAME COSTCO GASOLINE (LOC. NO. 1091) <br /> SHEADDREss REYNOLDS RANCH PARKWAY LODI 95240 <br /> 2680 ss,.et Number I 01rectlon I Street Nama Ci Zip coda <br /> HOME or MAHtNGADDRESS (H Different from Site Address) <br /> P .O. BOX 35005 Street Number Street Name <br /> CITY SEATTLE STATE WA ZIP 98124-3405 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (425) 313-6094 058-130-10 <br /> PHONE N2 Orr. BOS DISTRICT LOCATION CODE <br /> ( ) 4 CITY <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHEcKif BILLING ADDRESS■ <br /> Alexia inigues, Project Planner <br /> BUSINESS NAME PHONE# Exr <br /> Barghausen Consulting Engineers, Inc. (425)251-6222 7430 <br /> HOME or MAILING ADDRESS FAX# <br /> 18215 72nd Avenue South (425) 251-8782 <br /> Cm Kent STATE WA ZIP 98136 <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 ENvIRONMEWAL 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 JOAQuw <br /> COUNTY Ordinance Codes,Standards,STATE and FERAL laws. <br /> APPLICANT'S SIGNATURE: DATE::( 23 3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAMA OTBERAUTHORITEDAGENT■ Director of Real Estate Devleopment <br /> JJAPPLICANT is not the BILLLVGPARTY oojoj mthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATIO en 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: FUEL ADDITIVE EQUIPMENT AND TANK INSTALLATION <br /> COMMENra: <br /> AccEPTED BY: EMPLOYEE M. DATE:'_`��' <br /> ASSIGNED TO: EMPLOYEE#S DATE: <br /> Date Service Completed (if already completed): SERMcE CODE: 0 31 PIE: 2303 <br /> Fee Amount I ab d)ll k I Amount PaidI Payment Date /Y L <br /> Payment Type Invoice# Check# l` - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />