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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fueling Facility Doan iVOL) 1 Y<1 Z <br /> OWNER / OPERATOR CHECKIf BILLING ADDRESS ❑ <br /> Costco Wholesale Corporation, LLC <br /> FACILITY NAME Costco Gasoline " Costco Wholesale #1091 <br /> SITEADDRESsReynolds Ranch Parkway Lodi 95240 <br /> 2680 Street Number Ilan sCity Zip Coda <br /> HOME or MAILING ADDRESS (if Different from Site Address) Lake Drive <br /> 9 eat0!9bee <br /> Street Nama <br /> CITY Issaquah STATE WA Zip 98207 <br /> PHONE #1 Em APN # LAND USE APPLICATION # <br /> (425 ) 313-8100 <br /> PHONE #2 Eltr, BOS DISTRICT LOCATION CODE <br /> ( 425 ) 313-8100 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Jones Covey Group, Inc. - Robert Sills (Project Support) <br /> BUSINESS NAMEPHONE # Ext• <br /> Jones Covey Group, Inc, 714 975-4257 <br /> HOME or MAILING ADDRESS 9595 Lucas Ranch Road #100 - FAX # <br /> ( 909 ) 484-0300 <br /> CITY Rancho Cucamonga STATE CA ZIP 91730 <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 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY 01•dinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 3-26-18 <br /> PROPERTY / BUSINESS OWNERIZI OPERA•1.OR / MANAGER OTHER AUTHORIZED AGENT I@ Contractor <br /> IfAPPLICAArri.Y not the BILLING PgTY. proof of aetliorizatioii 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 j <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> I <br /> TYPE OF SERVICE REQUESTED: Penetration Repair S <br /> COMMENTS: Dispenser 3/4 UDC - Drain brine and perform repair of existing penetration tPt � at <br /> Epoxy. Perform all required testing . �E" <br /> MR � 1 2t7f3 <br /> SAN JOAGTU/ <br /> H NVIkOryMCA�NTY <br /> ACCEPTED BY: rA A EMPLOYEE #: DATE; .L M <br /> ASSIGNED To: , EMPLOYEE O DATE: <br /> Date Service Completed (If already completed) : SERVICE CODE: ( q <br /> P / E: OC •TJ c) <br /> Fee Amount: (415b 1Amount Paid YStP payment Date 31 av <br /> Payment Type Invoice # Check # Received By: <br /> ' <br /> EHD 48-02.025 O '2y j I SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />