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REUENLU <br />0 MAR 01 2016 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST ENVIRONMENTAL <br />e <br />r A t �1 t n!-nAOTR ACAIT' <br />Type of Business or Property <br />FACILITY ID <br />SERVICE REQUEST # <br />Gas Station <br />18721 <br />43 -7q 31 to <br />OWNER I OPERATOR <br />HOME or IIiIAILING ADDRESS 2535 Wigwam Dr <br />Costoo <br />CHECK If BILLING ADDRESS ❑ <br />FACRM DAME Costco <br />CrTY Stockton <br />SITEADDRES$ <br />2440 <br />Daniels <br />9336 <br />5 <br />street Number DirectionName <br />ACCEPTED BY: <br />Street <br />C <br />ASSIGNED TO: i <br />How or MAILING AoDREss (If Different from Site Address) <br />DATE: <br />999 Lake <br />Costco Wholesale Corporation[ <br />SERVICE CODE: <br />PIE: Z <br />gtreetNumber <br />Street Name <br />CITY Issaquah <br />STATE WA %P 98027 <br />PHONE #1 Exr- <br />APN # <br />LAND USE AwucAnoN d <br />( 209 366-7332 <br />PiiONE#2 Eicr. <br />( I <br />BOS DISTIVCT LocATIONCODE <br />CONTRACTOR / SERVICE REt' UESTOR <br />REQUESTOR Megan Mitchell <br />u t`fi <br />CHECK HBiL' N ADDRESS[] <br />RuSINESS NAME Elite IV ContfactorS <br />PHONE�I <br />209 <br />Ext <br />461-6337 <br />HOME or IIiIAILING ADDRESS 2535 Wigwam Dr <br />y SII 1 <br />FAX <br />#209 <br />461-6342 <br />CrTY Stockton <br />STATE CA <br />ZP 95205 <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 <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 />COUN'T'Y Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: �� DATE:2/29/16 <br />PROPERTY HUSENES5OWNER❑ OPERATOR! MANAGER ❑ OTHER AUTHORIZEDAGEIYT ElQfflce Assistant <br />IfAPPLICANT Is not the BILLIA'G 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. o <br />TYPE OF SERVICE REquESTED: Replace 91 STP Controller <br />u t`fi <br />REc 'y <br />COMMENTS: <br />�Q /,i <br />y SII 1 <br />J <br />NEg1'�v1,�a rjl�' <br />47- <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: i <br />EI41PLoYEE Vii: <br />DATE: <br />Date Service Completed (If ;[ready completedy: 2126/16 <br />SERVICE CODE: <br />PIE: Z <br />Fee Amount: <br />Amount Ph% <br />Payment Date <br />311111 <br />Paymant TypeV;�, <br />invoice # <br />Ch # � 1 �a / <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712043 <br />NT <br />4 <br />