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SAN JOAQL,, COUNTY ENVIRONMENTAL HEALTH T EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ,,O I"',S_ FACILITY ID# SERVICE REQUEST# <br /> Cosrco Whole Sale � Slew f0% ZI Z <br /> OWNER I OPERATOR Costco Wholesale <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Costco 658 Tracy <br /> SITEADDRESS 3250W Grantline Rd Tracy 95304 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Strwt Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Jones Covey Group,Inc. <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> Jones Covey Group,Inc. 888.972.7581 <br /> HOME Or MAILING ADDRESS 9595 Lucas Ranch Rd.Ste 100 FAX# ) 909-484-0300 <br /> CITY Rancho Cucamonga STATE CA ZIP 91730 <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 Or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and th a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE an D laws. <br /> APPLICANT'S SIGNATURE: DATE: 104/13 <br /> PROPERTY I BUSINESS OWNER❑ ATOR/MANAGER ORIZED AGENT ❑ Director of Service&Compliance <br /> If APPLICANT is not the BILLING PARTY Proof of authorization t0 sign IS required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: REGIFIVED <br /> U S <br /> COMMENTS: <br /> 2013 <br /> OCT n_"" " all SAN JOAQUIN COU <br /> NTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: y,o, - Na-101'-\ <br /> EMPLOYEE#: O DATE: f O I 3 <br /> ASSIGNED TO: ,—I EMPLOYEE#: 74 I DATE: <br /> Date Service Completed (k already Completed): SERVICE CODE: I09 , PIE: �;04 <br /> Fee Amount: 1$�7 Amount Paid76V� Payment Date w/-(h:3 <br /> Payment Type Invoice# Check# 1-S16'k Received By:alc� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />