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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST BCE # 10050 . 11a <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station FA0013810 �� ON (52, c4 /Z <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRES <br /> Costco Wholesale S <br /> FACILITY NAME <br /> Costco Gasoline Loc . No , 658 <br /> SITE ADDRESS 3250 West Grant Line Road Tracy 95377 <br /> Street Number Direction q1ranta e City zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> P . O . Box 35005 Street Number Street Name ^I ' ► / A <br /> � <br /> CITY STATE ZIP cc c, Y <br /> ` <br /> Seattle WA 98124 , V` � <br /> PHONE #1 EXT. APN tt LAND USE APPLICATION # AlAr <br /> ( 209 ) 830- 5340 23860006 CUP20 - 0003/419 - 0033 Sq IV 6 2422 <br /> PHONE #2 EXT, BOS DISTRICT LOCP/YC1 O CO <br /> ( 425 ) 313 -8100 T N �E RTM�N �y <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> M . Alexia Inigues CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE # EXT. <br /> Bar hausen Consulting Engineers , Inc . ( 425 ) 251 - 6222 <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 laws , <br /> APPLICANT' S SIGNATURE : 1.,: - _ DATE ; May 5 , 2022 <br /> PROPERTY I 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 . <br /> TYPE OF SERVICE REQUESTED : S T j� d as <br /> COMMENTS: <br /> S' 0 0 g4 (a o J� Cr4Lf U7r " O r/' 4e�5</*% Y7V 6ZZ � <br /> ACCEPTED BY : Q EMPLOYEE # : DATE : (P Z2 <br /> ASSIGNED TO : EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : _ ZGJ2 PIE : ,;5O2 <br /> Fee Amount : [7i� � Amount Paid l�s/ � O Payment Date �j 2 ?� <br /> Payment Type j Invoice # Check # 1 ZI'3 2 �?77 i Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />