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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID /# SERVICE REQUEST # <br /> Gas Station � / _ / (Z 00 ggg2 <br /> OWNER i OPERATOR <br /> Costco Wholesale CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Costco Gasoline ( Loc . No . 38) <br /> SITE ADDRESS 1630 Cast Hammer Lane Stockton 95210 <br /> Street Number Direction Streot Name City Zip Coda <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> P . O . Box 35005 Street Number Street Name <br /> CITY STATE ZIP <br /> Seattle _ WA 98124 <br /> PHONE #1 EXT. APN It LAND USE APPLICATION # <br /> ( 425 ) 313- 8100 094-280 - 13 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQU E STOR <br /> REQUESTOR <br /> M . Alexia Ini ueS CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE # ExT' <br /> Barclhausen Consulting Engineers , Inc . 425 251 - 6222 7430 <br /> HOME or MAILING ADDRESS FAX # <br /> 18215 72nd Avenue South ( 425 ) 251 -8782 <br /> CITY Kent STATE WA 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 : October 29 , 2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Authorized Agent for Costco Wholesale <br /> /f 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 information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the Same time It IS provided to me Or <br /> my representative . T `y� P /�/ <br /> TYPE OF SERVICE REQUESTED: �jf S / r G/ ' S ' <br /> COMMENTS : p (OV <br /> 0 ,9 <br /> 'SAN JO AQ 2021 <br /> IEWIa Tti o p��N°ANT y <br /> Rr <br /> ACCEPTED BY: SGC �r ��s EMPLOYEE # : DATE : <br /> ASSIGNED TO :�/n n f `/ 7 ^G� ��� EMPLOYEE # : DATE: <br /> Date Service Completed (If Already completed) : SERVICE CODE:f � _- 2 �7 P 1 E23O 4j3- <br /> Fee Amount : �' r v Amount Pal 7�S(a� � Payment Date A <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-02.5 SR FORM (Golden Rod) <br /> 07/17/08 <br />