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SERVICE REQUEST <br /> Type of Business or Property FACIL1rY IDA SERVICE REQUEST# <br /> Gasoline <br /> p+0c)& 36 75.1 <br /> B&LNG PMtY 0 <br /> OrwR I OPERATOR <br /> Costco Wholesale Corporation <br /> Foca yNAVE <br /> IR <br /> SREADMSS 1616 E Hammer Lane, Stoocck n, CA TYM <br /> s„a„ <br /> fdailing Address (N Oifftrem from Site Addresol <br /> 999 Lake Drive <br /> STAT Zp <br /> Cm <br /> Issaquah WA 98027 <br /> PHONE91 aT APNd LANAUSEAPPUCAT10Nt <br /> 425) 313-6100 <br /> PHONE t2 Ea. SOS Deism LOCATpN COOS <br /> COKTHArCTOR I SERVICE REGMSTOR <br /> Bntnfa PARTY$X <br /> REGJFSTOR <br /> Costco Wholesale Corporation —\..t <br /> PHONE <br /> Buso Ess NAME -7 <br /> A I <br /> Costco Whole 'al 425 b J <br /> 999 Lake Drive <br /> CrrY Issaquah - STATE WA ZP 98027 <br /> BILLING ACKNOWLEDGEMENT: L me w4ersigred Proe"Of bu%Vm ownu,optramr or aumo'sed fig"of sae' aanvNerlge mA as sea andor V*d SPOcik <br /> PVaX HEkM S&av S&ma(5u+ WAx NEAtM Pnurur Harry Marga assodobd wh M p qc o'ach3/%a be tried m mt or my business as IdenSW m tds lnm <br /> I also cx*rat I have pwipared Mis apPiosbon and#sat the work To be ptdomed el be trite r=yw=wM as SAN JU t Count/O*MM Cada.SS+dsds.STATE and <br /> FEOEW la•Ms APrtaCArri SlriuTurE: .ti..,. <br /> P9lnl&16NEss Oraax OPERATOR AIIJUCE ❑A OnotAM+a�AG04T ❑ <br /> RaPFw Au•-r.r-r M(rtl-- <br /> N�nrw•runa ar 8YC4Pum OreetMaAia�rryi6rgi'M Tit), <br /> AUTN0RRATl0N TO RELEASE INE0RMAM When appambie.L ft mMitr a opanmrof be prop"btled at he ab° sat add ess.Meer ausrorW be rOWN of <br /> any and 1a raaWe,geotedirJral data andUt Yrviavrcntaasim assrsmsk k46rmadm b Qr SNI JuuYrv+CaanY PU0.iC HEAttM SEtNLEs Enviav+Me+TK HEKTH DrApoM Y tom <br /> as e is Mil"and at are same Gro it is provided b me IX my rep asekaew• <br /> TYPE OF SERYSE REQUESTED: <br /> CCMYEKIS: G•! <br /> RECEIVED <br /> AUG - 5 zooz <br /> SAN JOAOIJIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> NVIgMMENTAI.HEALTH DIVISION <br /> INSPECTOR'S SnIu11tRE CONTRACTOR'a516KA � ,,,�� <br /> APPROVED eDATE-Y: E11PlDYE`->7: <br /> ASSGNMTO. EYNAYFE* DATE: <br /> Date Service CampkW Of*"dq wwpland SOYMCODE: <br /> Fee Amount: _ •�1�21 Amount Pdd,/ <br /> Payment Typo i t7aacki yf �' <br />