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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 v � 3 69= sem+ cocv <br /> OWNER / OPERATOR <br /> Costco Wholesale CHECK IfBILLING ADORESSO <br /> FACILITY NAME <br /> Costco Gasoline ( Loc . No . 1091 ) <br /> SITE ADDRESS 1JJ Reynolds Ranch Parkway Lodi 95240 <br /> 286 " Street Number Direction Street Name c1tvZI 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 STATE ZIP <br /> Kent WA 98032 <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 425 ) 251 - 6222 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Barghausen Consulting Engineers , Inc . CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Costco Wholesale do Barghausen Consulting Engineers , Inc . 425 251 - 6222 <br /> HOME or MAILING ADDRESS FAX # <br /> 18215 72nd Avenue 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 /> 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 : �—E— � DATE : 9/5/2023 <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 . n <br /> TYPE OF SERVICE REQUESTED: tA S T 1 ' ! v 1 n v r P1r a,-v) Cku PAYME YT <br /> COMMENTS: <br /> SEP 1 1 023 <br /> SAN JOAQUIN CC LINTY <br /> ENVIRONMENI AL <br /> HEALTH DEPART AENr <br /> ACCEPTED BY: d < EMPLOYEE #: DATE: 5 T <br /> ASSIGNED TO : P, 1V /sr O �.J EMPLOYEE #: DATE: 4? h 4? <br /> Date Service Completed (if already completed) : SERVICE CODE: ! qf, � 2 9' IE: <br /> •/ 3� 9 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type 144Invoice # Check # ' d 13 l 2 �6( Received By : <br /> / Z <br /> EHD 48-02-025 � [ SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />