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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS QrJ <br /> Costco wholesale c/o Earghausen Consulting Engineers, Inc. <br /> FACILITY NAME <br /> Costco Retail Fueling Facilit Location No. 658 <br /> SITE ADDRESS 3250 West Grant Line Road Tracy 95377 <br /> Street Number I DlractionStreet Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18215 72nd Avenue South <br /> Street Number Street Name <br /> CITY Kent STATE WA ZIP 96032 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 425 ) 251-6222 238-600-06 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1%-.--C-0NTRACT0R--Z>ERVICE REQUESTOR <br /> (p r/ <br /> REQUESTOR ozA7 T[]'Jf� Our -ive i y CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME L PHONE If EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar=s- and <br /> FEDER <br /> APPLICANT'S SIGNATURE:X �AIIV40DATE <br /> Li His bocK <br /> PROPERTY/BUSINESS OWNER® PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑Fny onm n a1 Comliance Mar. <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tiile <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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 10050.002.pdf <br />