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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property /-1FACILITY ID # RACEREQUEST # <br /> Fueling Facility F/f a0 / 3 Y/ Q ,5 � � W o15 L <br /> OWNER / OPERATOR <br /> Costco Wholesale Corporation CHECK If BILLING ADDRESSO <br /> FACILITY NAME Costco 658 <br /> SITE ADDRESS 3250 W Grantline Rd . Tracy 95304 <br /> 3250 <br /> Street Number Direction Street Name City Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 209 ) 834- 1247 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Bruno Espinoza - Jones Covey Group , Inc . CHECK if BILLING ADDRESS <br /> BUSINESS NAME Jones Covey Group , Inc . PHONE # EXT, <br /> 909 543 - 8904 <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 or <br /> 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 Ordinance Codes , Standards, STATE and FEDERAL laws . _ <br /> APPLICANT'S SIGNATURE : DATE : 10/27/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Jones Covey Group - Permitting <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 MA� <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is proVlairy elv <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : S' % t 2 <br /> OAN JOAQU <br /> COMMENTS : IN COUNT <br /> Ilr-airr '�ONNI ENTALI <br /> On 10/10/2022 Replaced a like for like Defender Series Drop Tube located on Tank 2 87B . Conducted 201 . 3 <br /> Static Pressure Performance Test and Drop Tube integrity Test . Both tests passed with no issues found . <br /> ACCEPTED BY: Q \ EMPLOYEE # : DATE: ZZ <br /> ASSIGNED TO : .4a4v Pr" " EMPLOYEE # : DATE: <br /> Z <br /> Date Service Completed ( if already completed ) : 0// 2Z SERVICE CODE : 0 —2q J P , <br /> E : 0 <br /> Fee Amount : a% J Amount Paid 3 — Payment Date lI « Z 1ib <br /> Payment Type G Invoice # Check # J Received By : <br /> 07/17/08 4012. l ! / ll/L1i Rod ) <br /> �`' � � <br />