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DocuSign Envelope ID: 2F173BE3-D39CA7D3-A993-65B9F76377E9 AIV JUAQUIN ' + UUN I Y I= NvIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Dt� 33 Type of Business or Property OaS. Sf fjlj� FACILITY ID # SERVICE REQUEST # Costco Gasoline (Loc. No. 038) FA0024496 OWNER / OPERATOR 13 CHECK If BILLING ADmJ Costco Wholesale, c/o Barghausen Consulting Engineers , Inc. FACILITY NAME Costco Gasoline (Loc. No. 038? SITE ADDRESS 1630 East Hammer Lane Stockton 95210 Street Number Diroction Street Name City 21 Code HOME or MAILING ADDRESS (If Different from Site Address) c/o 18215 72nd street Number Ave S. Street Name CITY STATE ZIP Kent WA 98032 PHONE #1 ExT APN # LAND USE APPLICATION # ( 425 ) 251 -6222 094-280-13 N/A PHONE #2 ExT• BOS DISTRICT LOCATION CODE ( ) N/A N/A CONTRACTOR / SERVICE RE, QUE ME niCHECK If BILLING ADDRESS El Alexia a Inigues, Authorized Agent BUSINESS NAME PHONE # EXT Barghausen Consulting Engineers, Inc. 425 251 -6222 HOME or MAILING ADDRESS FAX # 18215 72nd ave S . ( 425 ) 251 -8782 CITY Kent STATE WA ZIP 98032 BILLING ACKNOWLEDGEMENT: t, the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . 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 COUNTY Ordinance Codes, Standards, STATE and to 06RnA Laws. APPLICANT' S SIGNATURE : F�at2 8n7- '4-ea ' DATE : 2 /9/2021 PROPERTY / BUSINESS OWNER E] OPERATOR #RQM Re8pFu1 OTHER AUTHORIZED AGENT ® Authorized Agent of Owner If APPLICANT IS not the BILLING PARTY, proof of authorization to Sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable, I , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it is provided to me or my representative . TYPE OF SERVICE REQUESTED: Removal of Healy CAS and Installation of ARID Permeator and associated equipment M r l7 / U COMMENTS: . ACCEPTED BY; EMPLOYEE #; DATE; a ASSIGNED T0 : I , S D EMPLOYEE #: DATE; �14Z3i Date Service Completed (if already Completed) : SERVICECODE; I Pi E0t230cf Fee Amoun . � p f G� Amount Paid Payment Date Payment Type Invoice # Check # Received By : EHD48-02-025 ravo�e � t7 "" / / - WSdRM (Golden Rod) 07/17108