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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 Gasoline Station 241q % 6' SRX8�i104 <br /> OWNER I OPERATOR <br /> Costco Wholesale CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Costco Gasoline ( Loc . No . 38 ) <br /> sIT1630Ess E Hammer Lane Stockton 95210 <br /> Street Number Direction I Street Name cityZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 18215 72nd Avenue South <br /> c/o Barghausen Consulting Engineers , Inc. Street Number Street Name <br /> CITY Kent STATE ZIP <br /> WA 98032 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> 4251251 - 6222 <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Barclhausen Consulting Engineers , Inc . CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Costco Wholesale c/o Bar hausen Consulting Engineers , Inc . ( 425 ) 251 � 6222 <br /> HOME Or MAILING ADDRESS FAX # <br /> 18215 72nd Avenup South <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 : �— DATE : 9/5/2023 l <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Authorized Agent <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 : u S j'rj•� �.- / /I� v� RECEIVED <br /> COMMENTS : W I SEP 1 1 20 <br /> 2 3 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : S N4 � EMPLOYEE M DATE : <br /> ASSIGNED TO : n �SDet �`� EMPLOYEE #: DATE: /23 y <br /> Date Service Completed (if already completed ) : SERVICE CODE: / p _ qcf PIE; � o q <br /> o <br /> Fee Amount: � 2 �' �' Amount Paid G �— Payment Date �r <br /> Payment T <br /> y Type � Invoice # Check # Received By : <br /> i <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/ 17/08 <br />