Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gas Station FFA IC)02 � � � K OV ULI <br /> OWNER / OPERATOR <br /> Costco Wholesale CHrcK If BILLING ADDRESSO <br /> FACILITY NAME Costco # 0038 <br /> SITE ADDRESS Hammer Lane Stockton 92510 <br /> n7�1 1E Hamp � e Lan <br /> lY 8lreet Number Dlrectlon Street Name city Vp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 999 Lake Drive Street Npmber Street Name <br /> CITYIssaquah WA STATE ZIP 95210 <br /> PHONE #1 EXT. APN 4 LAND USE APPLICATION # <br /> ( 209 ) 478 -- 2040 <br /> PHONE 92 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Alan Evans CHECK IfBILLINeADORE <br /> SS <br /> BUSINESS NAME PHONE # Exr. <br /> Wayne Perry Inc 714 826 0352 <br /> HOME or MAILING ADDRESS FAX # <br /> 8281 Commonwealth Ave (714 ) 523 7880 <br /> CITY Buena Park STATE CA ZIP 90621 <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 Ordinance Codes, Standards, STATE at EDERAL llaws . <br /> APPLICANT ' S SIGNATURE : / V ' DATE : 9 / 8 / 2022 <br /> PROPERTY t BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> ffAl'PLICANT is 1101 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 <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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative . <br /> TYPE OF SERVICE REQUESTED: (tet f T )42Q trrJ / Z " � " / YJ PV <br /> COMMENTS: SB989 repairs permit PA ENr <br /> LVED <br /> SEP 0 2022 <br /> SAENVIAUUIN oUNry <br /> HEALT RoNA7 NTAL <br /> H DEpA TM1fENi <br /> ACCEPTED BY: ,���� ��/�-i`�� EMPLOYEE #: DATE: � � 2Z <br /> ASSIGNED TO . S /zy/ <br /> Ll� G'C1 (� ���J` �u EMPLOYP #: DATE: 7� <br /> Date Service Completed (if already completed) : SERVICE CODE:/ g�� ��� Y / E$ 3U <br /> Fee Amount : / c- 0 Amount Paid Payment Date Z <br /> Payment Type V l Invoice # CFyeC I ?) Received By : <br /> EHD 48-02-025 �/ b / j 1,,2,,R FORM (Golden Rod) <br /> REVISED 11 /17/2003 666 [[[ <br />