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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Wholesale Retail <br />FACILITY ID # <br />:1--A 00 1 LI I .3 I <br />SERVICE REQUEST # <br />e 00 si3soltiso <br />OWNER / OPERATOR Costco Wholesale CHECK if BILLING ADDRESS EJ <br />FACILITY NAME COStC0 Wholesale <br />SITE ADDRESS 3250 <br />Street Number <br />W <br />Direction <br />Grantline Rd <br />Street Name <br />Tracy <br />City <br />95304 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( 425) 313-8634 <br />APN # <br />23860006 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR Sam Sanchez CHECK if BILLING ADDRESS X <br />BUSINESS NAME Cushing Terrell PHONE # <br />( 702 ) <br />Ex-r. <br />513-2006 <br />HOME or MAILING ADDRESS 800W Main St #800 FAX # <br />( ) <br />CITY Boise STATE ID ZIP 83702 <br />BILLING ACKNOWLEDGEMENT: 1, 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 />APPLICANT'S SIGNATURE: <br /> <br /> DATE: 9/9/2022 <br /> <br />PROPERTY / BUSINESS OWNERO OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT C83 Project Lead <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 <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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />electronic plans <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6211 DATE: 11-2-22 <br />ASSIGNED TO: Kadeanne Linhares EMPLOYEE #: 4589 DATE: 11-2-22 <br />Date Service Completed (if already completed): SERVICE CODE: 61 P I E: 1601 <br />Fee Amount: 468 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />SR FORM (Golden Rod) Payment 152284761 EHD 48-02-025 <br />REVISED 11/17/2003