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From:Belshire Environment Fax:(949)460.5210 To: 2094640136@rctax.con Fax: +12094640138 Page 3 of 3 0310712016 7:06 AM <br /> SAN JOAQUIN*FNTY ENVIRONMENTAL HEALTH 0ARTMENT <br /> SERVICE REQUEST <br /> Type of Susinessbr Property FACILITY ID# SERVICE REQUEST# <br /> Wholesale/Retail Warehouse FA Do l�10 SK0074 3 L' l <br /> OWNER/OPERATOR <br /> Costco Wholesale Inc. # (pS CHECKIfBILLINGADDRE55 <br /> FACILITT NAME Costco 0658 <br /> SITE ADDRESS W Grantl i ne Rd Tracylq S 30`� <br /> 3250 Street Number Direction Street Name Ci Zip Code I lei J� <br /> HOME Or MAIL-NGADDRESS (If Different from Site Address) 999 Lake Dr. <br /> Street Number Street Name <br /> CITY Issaquah STATE WA zip 98027 <br /> PH0NE#1 ExT• APN# LAND USE APPLICATION# <br /> (425) 423-7653 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mike Ellis <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Belshire Environmental Services, Inc ( 951 ) 675-7233 <br /> HOME or MAILING A DDRESS FAx# <br /> 25971 Towne Centre Dr. ( } <br /> CITY Foothill Ranch STATE CA zip 92610 <br /> BILLING ACKNOXVLEDGENTENT: 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 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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 7-nk,,P- DATE: 3/7/2016 <br /> PROPERTY/sus,NESsOwNER❑ OPERATOR/NlANAG1=.1a ❑ OTHER AurHoRrZEDAGENM Project Manager <br /> 1fAPPL1C,4NT is not the R1LLINGPAATY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE ENTFORf ATION: 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 Coul,;TY 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: U��- S ' ` <br /> COWKNTS: RECEIVED <br /> MAR 0 7 2016 MAR 0 7 2016 <br /> SAN JOAQUIN COUN7Y <br /> ENVIROMENTAL SWRONMENTALHE&TH <br /> HEALTH DEPARTMENTRVICE,� <br /> ACCEPTED BY: E:MPLOYE:E:#: DATE: 3j-7 JI <br /> ASSIGNED TO: � chc� MCC"6W+V1ekA EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed). SERVICE CODE: —"' re PIE: 2�-AcxL/-, <br /> Fee Amount: % Ip.�L Amount Paid O , Payment Date <br /> Payment Type ,�� Invoice# Check# 06 (pys , Received By: <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> RF1rICFn ti1l17nnn3 <br /> Received Time Mar. 7, 2016 7: 06AM No. 0542 <br />