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DocuSign Envelope ID : 57852BDB-FD2B-4170-B5C8-435307C98954 <br /> JAN JUAUUIN koUUN I Y MNVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station FA0013810 Cog Ll ( 03 <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 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 # LAND USE APPLICATION # <br /> ( 209 ) 830-5340 23860006 CU P20- 0003/D 19- 0033 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 425 ) 313-8100 <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> M . Alexia Inigues CHECK If BILLING ADDRESSE] <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 : a tea ,. December 3 , 2021 <br /> e.:ocenixerF.zo_ <br /> F DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Authorized Agent for Costco Wholesale <br /> If APPLICANT is not the BILLING PARTY, /)roof 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 /> 'Tt <br /> TYPE OF SERVICE REQUESTED : ► ju, /S �I r,�1 f7 ? 1 Q r Cj 7/ <br /> 141 <br /> COMMENTS: ` / ! Lam ' ` I t�i�7 rC. � V ! / , y 11� (J (� V � J DEC <br /> �/ l�tJ V SAN JOCgIQ. 3 2421 <br /> HEA T OE ARTAL <br /> Nry <br /> MENT <br /> ACCEPTED BY: f ,l �/J !�� EMPLOYEE # : DATE : /,� , <br /> LZIASSIGNED TO : v' �/7 nG�1 , EMPLOYEE #: DATE:X177VT ?? <br /> Date Service Completed ( if already completed) : $ERVICE CODE : P , � 4 <br /> Fee Amount: a& 4pv Amount Pal U� Payment Date ( l <br /> Payment Type W Invoice # Check # /3S 2 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />