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1%-� *400f <br /> SAN JOAQUIN COUNTY ENYHtONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERV ICE REQUEST# <br /> FA0020431 <br /> AR0036486 J ll <br /> OWNER/OPERATOR COSTCO WHOLESALE CHECK If BILLING ADDRESS13 <br /> FACIL"NAME COSTCO GASOLINE (LOC. NO. 1091) <br /> SITEADDRE" 268014 <br /> r REYNOLDS RANCH PARKWAY LODI 95240 <br /> street e e Gil 2i e <br /> HOME Or MAti eADDRESS (If Different from Site Address) <br /> P .O. BOX 35005 street Number Streal Name <br /> Cm SEATTLE STATEWA zip 98124-3405 <br /> PHONE#t APN# LAND USE APPLICATION# <br /> (425 ) 313-6094 058-130-10 <br /> PHONE#2 Exr• SOS DISTRICT LOCATION CODE <br /> ( ) 4 1 CITY <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REODESTOR ALEXIA INIGUES, PROJECT PLANNER CHECKMBILLINGADDREss. <br /> BUSINESS NAMEPHONE# ' <br /> BARGHAUSEN CONSULTING ENGINEERS, INC. 425 251-6222 7430 <br /> HOME or MAILING ADDRESS FAX# <br /> 18215 72ND AVENUE SOUTH (425) 251-8782 <br /> CITY KENT STATE WA ZIP 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 we 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 JoAQUM <br /> COUNTY Ordinance Codes,Standards,STATE and FED/ aws. <br /> APPLICANT'S SIGNATURE: l DATE: (l2 I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHERAUTHOrsizEDAGENT 0 Director of Real Estate Development <br /> JJAPPLlCANT is not the BILLING PARTY.proof oath iztrtion to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: n app able,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and is, geotechnical data and/or environmentattsite 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 SEwcE REauESTED: RETROFIT EXISTING TANKS FOR FUEL ADDITIVE INSTALLATION <br /> COMNEM: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (If already completed): SERNCE CODE: 1 9 8 PIE: 2308 <br /> Fee AmAmount Paid ,i7' Payment Date <br /> Payment Type Invoice# Check# Received By: /mak <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/201:5 <br />