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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RETAIL WAREHOUSE S S 9 <br /> OWNER/OPERATOR COSTCO WHOLESALE CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME COSTCO WHOLESALE <br /> SITE ADDRESS 1616 E HAMMER LANE STOCKTON 95210 <br /> Street Number DIMOtIon Street Name CIIN Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number stmet Name <br /> CITY STATE ZIP <br /> PHONE#I En. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> ERIK CHUDY CHECK IT BILLING ADDRESS <br /> BUSINESSNAME CUSHINGTERRELL PHONE# EXT. <br /> 208 577.5695 <br /> HOME or MAILING ADDRESS 800 W MAIN STREET#800 FAX# <br /> CITY BOISE STATE ID ZIP 83702 <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 and FEDERAL laws. <br /> n /T <br /> APPLICANT'S SIGNATURE: DATE: // _ C C <br /> PROPERTY/BUSINESS OWNER❑ 'OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13i- <br /> Y.4PPL/CANT is not fhe BauNG PAR_rte,,proof of authorization to sign is required rtrle <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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: plan review p\ RECOVED <br /> COMMENTS: I` f <br /> EC 1 0 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 12-8-20 <br /> ASSIGNED To: Steven Shih EMPLOYEE M 7380 DATE: 12-8-20 <br /> Date Service Completed (If already Completed): SERVICE CODE: 523 P I E: 1601 <br /> Fee Amount: 456 Amount Paid y (�(7 Payment Date 12 x!2.0 <br /> Payment Types Invoice# Che k# I 7-1 Received By: <br /> EHD 48-02-025 payment confirmation# 117791686 SR FC(M(Golden Rod) <br /> REVISED 11117/2003 <br />