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SAN JOA IIIIY COUNTY ENVIRONMENTAL HEALTH 1li�:PARTMENT <br /> Q VI <br /> SERVICE REQUEST Pq3 <br /> Type of Business or Property FACILRY(D# SERVICE REQ ST# <br /> Whole Sale Warehouse <br /> OWNER J OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Costco <br /> FACILITY NAME Costco#1091 <br /> SITE ADoss£SS <br /> 26N„.,. Din Reynolds Ranc ay Lodi 95 �ae <br /> HOME Or Il NL(w ADDRESS (if Different from Site Address) <br /> Sheet N4mber <br /> CITY STATE Zip <br /> PHONE#1 EXT• APN# C'r� LAND USE APpL1rJ mN# <br /> ( 209) 366-7332 oc` v " <br /> PryONE 1F2 BOS E STRIST LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CNEcx if BILLING ADDRE55 <br /> Kim White <br /> BUSINESS NAME PNDNE# E T. <br /> Elite IV Contractors ( 209) 461-6337 <br /> HOME or MAILING ADDRESS FAX.# <br /> 2535 Wigwam Dr. ( 209 ) 461-6342 <br /> CITY Stocidon STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, <br /> a 6mowledge that all site and/or project specific F.NVIRONNIENPAL HEALTH©EPARTNwNT 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 app tion and that the work to ormed will be done in accordance with all.SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S A and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ��`�C/�—'uA. DATE: n/ <br /> PRO]PERTYIBUSKiESSOWNERO OYEBAToR/mAKAGER 13OTHERATTTIIORRIZMAGENTo t t� <br /> I•f APPLICANT is not the Bffj-NG PARTY,proof of am*orhalion 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 ENviRoNMEN7AL HEALTH DEPART.kENNT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERMCF1040 W Vac Sensor Replacement 87 A Vent!Cold Start ' <br /> COMMENTS: R - IR2 n ra n <br /> A�PI� %0,5 <br /> APR 2 2 285 <br /> SAS,OAQUM COUNTY . <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: \ EMPLOYEE#: DATE: _ 15 <br /> ASSIGNED TO: c. s� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CouE: l q PI E: e2 a�- <br /> Fee Amount: '�('[}°` Amount Pal 3?0, Payment Date <br /> Payment Type �_ Invoice# Cir # Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />