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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 v ��� y 4gL � <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Costco Wholesale <br /> FACILITY NAME <br /> Costco Gasoline ( Loc . No . 1091 ) <br /> SITE ADDRESS 2680 1 Reynolds Ranch Parkway Lodi 95240 <br /> Street Number 0lrection Street Name City Zip Code <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 058- 650- 140 -000 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS 0 <br /> M . Alexia Inigues <br /> BUSINESS NAME PHONE # EXT. <br /> Bar hausen 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 /> 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 <br /> rr laws . <br /> APPLICANT' S SIGNATURE : i l—�� DATE : November 5 , 2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Authorized Agent for Costco Wholesale <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 information <br /> 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 <br /> my representative . PAYMENT <br /> TYPE OF SERVICE REQUESTED : <br /> HUI <br /> COMMENTS : �/� �( �-� S <br /> SAN JOAQUIN COUNTY, <br /> ENVIRONh1E.NTA,t <br /> HEALTH OEPARTI11EtdT <br /> ACCEPTED BY` � v�- EMPLOYEE # : DATE : <br /> ASSIGNED TO : t/f / r� EMPLOYEE M DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE: lqp . �/ P 1 Ei�206)! <br /> Fee Amount / 56, OP Amount Paid Payment Date I l r Z>V !/1 <br /> 5k <br /> Payment Type l ��- Invoice # Chet" 3 $ D 3 Received By: <br /> tl � ly/ � � vt <br /> EI-ID 48- 02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />