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SAN JOAQU*COUNTYENVIRONMENTALHEALTO EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> +S� SERVICE REQUEST# <br /> OWNER/OPERATOR /b <br /> Costco Wholesale c/o Barghausen Consulting Engineers, Inc. r.../.1r <br /> CHECK if BILLING ADDRESS LJ <br /> Fpcam NAME <br /> Costco Retail Fuelin Faeilit Location No. 658 <br /> SITE ADDRESS 3250 West <br /> Grant Line Road Tracy 9577 <br /> SVeet Number Direction Street Name <br /> . city <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 19215 72AvezI coae <br /> nd Avenue South <br /> Street Number SVeet Name <br /> CIN Kent <br /> STATE WA ZIP 98032 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> I 42 1 251-6222 238-600-06 <br /> PHONE 92 EXT. SOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTORERVICE REQUEST <br /> REQUESTOR <br /> Owner/Operator as listed above CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE If EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> ( 1 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Sta $TATP,an be P1 Wt I S <br /> APPLICANT'S SIGNATURE: N09d� DATE: <br /> Environmental Compliance <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Manaaer <br /> /fAPPLICANT is not the BILLING PARTY proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: 4 q / p \ <br /> COMMENTS: JUN 2 2008 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE Z DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: ✓ Amount Paid a 1{.k , 6 (� Payment Date IA( 2_1A I <br /> Payment Type ✓= Invoice# Check# Received By: ,- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 10050.002.pdf <br />