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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # OERIVICE REQUEST # <br /> Gas Station FA0020431 C 60V FJ � <br /> OWNER / OPERATOR <br /> Costco Wholesale CHECK If BILLINGADDRES5 <br /> FACILITY NAME Costco Gas Loc . No . 1091 <br /> SITE ADDRESS 2680 Reynolds Ranch Parkway Lodi 95240 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18215 72nd Avenue <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Kent WA 98032 <br /> PHONE #'I EXT. APN # LAND USE APPLICATION # <br /> ( 425 ) 251 -6222 <br /> PHONE #T EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Ind ueS CHECK if BILLING ADDREssLU <br /> BUSINESS NAME PHONE # ExT. <br /> 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 to /A 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 laws <br /> APPLICANT' S SIGNATURE : DATE : June 13 , 2019 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Senior Planner <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 assessment inf mation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided <br /> my representative . • a� � � <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> SAN ) 4 019 <br /> FN OAQUf <br /> c_(J�U�' ` � �� 8�1 71?O)VAIJ�1V )U1 10y <br /> y DEPART A <br /> e ENr <br /> ACCEPTED BY : � v� /^-�f EMPLOYEE M /4 DATE ; <br /> ASSIGNED T0 : fir• EMPLOYEE #; 0066%9' DATE : <br /> Date Service Completed (if already completed ) : SERVICE CODE: �Gj PIE: <br /> I� ee Amount: Amount Pai q � <br /> � • v� Payment <br /> << Date 6111167 <br /> Payment Type Invoice # / Check # 47CI R iced ed By: <br /> EHD 48-02- 025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />