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{ <br /> SAN JOAQOUNTY ENVIRONMENTAL HEALPARTMENT <br /> SERVICE REQUEST 10 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fueling Facility 141� 02 Lf r�1 ti 2 0 39"(0 <br /> OWNER/OPERATOR <br /> Costco Wholesale CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Costco Gasoline <br /> SITE ADDRESS 322 East Harney Lane Lodi 95240 <br /> Street Number Direction Street Name city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 999 Lake Avenue <br /> Street Number Street Name <br /> CITY <br /> Issaquah STATE 98027 -8990 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (425 ) 313-8100 058-130-10 <br /> PHONE#2 EXT BOSDISTRICTr LOCATION CODE <br /> 1 C L <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS❑ <br /> npnnisRnrk <br /> BUSINESS NAME PHONE# EXT. <br /> Costco Wholesale 425 313-8100 <br /> HOME or MAILING ADDRESS FAX# <br /> 999 Lake Drive (425 ) 313-8105 <br /> CITY STATE Zip <br /> Issaauah WA 7 <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 DEPARTMEN'r 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 certifv that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY 01-(linance('odes,Stan lards,STATE and FE--DEER�AL laws. <br /> APPLICANT'S SIGNATURE: yuy�1/ DATE: 06/28/10 <br /> PROPERTI /BCSINESSOWNER® OPERATOR/MANAGER ❑ OTNERAtTUORIZEDAGENT❑ Environmental Compliance Manag <br /> 1f.11'1111C.LNT is 1101 the 131LLLV(;RORTY.proof of uutlrorizution to sign is required Title <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 HEALTtt DEPARTMENT as Soon as it is available and at the swine tulle It is <br /> provided to ille or my representative. <br /> TYPE OF SERVICE REQUESTED: U S rO/AJ -.JrA(.L_4-T7 0 A) P11 <br /> COMMENTS: — <br /> JUL - 2010 <br /> SANJOAQUIN COUN <br /> ENViHONMENTAL <br /> y r'TH DEPARTMENT <br /> ACCEPTED BY: Ll��I EMPLOYEE#: a 3 DATE: .7 I <br /> IA 0 <br /> ASSIGNED TO: C 4C 04-701 7-- EMPLOYEE#: ��ZZ DATE: / //,o <br /> Date Service Completed (it already completed): SERVICE CODE: 03 PI-E: .3 <br /> Fee Amount: c?2-0 cT Amount Paid4l $l 1- ® Payment Date <br /> Payment Type ✓ x Invoi�Jce^# Check# ,gA3 V_ � Received By: <br /> EHD 48-02-025 fWL!10`o?/��/ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 !U/(/�/11..�/ C,(U t 14573.006.pdf <br />