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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Gasoline FA0018721 Sgop3b�q <br /> T <br /> OWNER/OPERATOR <br /> Costco Wholesale CHECK if BILLING ADDRESS <br /> FACILITY NAME Costco Wholesale#1031 <br /> SITE ADDRESS 2440 Daniels Street Manteca 95336 <br /> Street Number Direction Street 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 98032 <br /> PHONE#1 EXT. F�P <br /> N# LAND USE APPLICATION# <br /> (425) 251-6222 24153001 MPM 18-113 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inigues CHECK if BILLING ADDRESSE] <br /> BUSINESS NAME PHONE# EXT. <br /> Costco Wholesale c/o Bar hausen Consulting Engineers, Inc. 425 251-6222 <br /> HOME or MAILING ADDRESS FAX# <br /> 18215 72nd Avenue South (425) 251-8782 <br /> CITY Kent STATE WA ZIP 98032 <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 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <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 assessmen formation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It Is provim <br /> my representative. �I/l`►NT <br /> TYPE OF SERVICE REQUESTED: <br /> J <br /> COMMENTS: 720,9 <br /> MAR 19 2019 IV�RO�INCOU <br /> TyOEPgRTA ry <br /> ENVIRONMENTAL HEALTH MENTT <br /> ACCEPTED BY: 1 0-0 EMPLOYEE#: 2 fit / DATE: ':5! Cj_I C <br /> ASSIGNED TO: �� j l EMPLOYEE#: C'+�4�� DATE: 3✓� �1� — r <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: <br /> Fee Amount: Amount Paid,U-D Payment Date <br /> Payment Type �--+� Invoice# Check# L Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />