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=m:Alltech Petro Inc. (12094683433)16:04 08123110GMT-04 Pg 06-08 <br />SAN JOAQUIN "Y ENVIRONMENTAL HEALTH DORTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />/ <br />R ICE REQUEST# <br />a ) Lo--� 0. )— <br />—1 <br />OWNER I OPERATOR <br />Costco Wholesale <br />PHONE# Eur. <br />CHECK ifBILLINOADDRESS <br />FACILITYNAME Costco Wholesale Manteca, <br />CA <br />HOME or MAILING ADDRESS P.O. Box 4208 <br />SITE ADDRESS <br />2440 Street Number <br />I <br />Daniel St. <br />Street Name <br />EMPLOYEE #: <br />Manteca <br />c1tv <br />95336 <br />Zp code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />16 C) Payment Date <br />STATE ZIP <br />PHONE #1 E)r• <br />( ) <br />APN # <br />.Ceek#'�FyO <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Isaac Anderson <br />CHECK IfBILuNoADnRESs� <br />BUSINESSNAME Alltech Petro Ca <br />COMMENTS: <br />PHONE# Eur. <br />om <br />- <br />yOAd�tt� CuJA1sw <br />F� pE.P�11A <br />ACCEPTED BY: -ril UL -1 <br />(209 532-7320 <br />HOME or MAILING ADDRESS P.O. Box 4208 <br />FAX # <br />EMPLOYEE #: <br />(209) 533-2650 <br />CITY Sonora <br />STATE CA ZIP 95370 <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 mud 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 />PROPERTY / BUSINESS OWNER OPERATOR I MANAGER ❑ <br />DATE: 08-2-2010 <br />OrMERAUTHORizEnAGEN IZ Service Technician <br />If APPUCAW is not the BILLING PARTY proof of authorization to sign is required Till e <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 />�^� <br />TYPE OF SERVICE REQUESTED: NIA �(2(} -(� <br />4 � /Q f � <br />PP" <br />COMMENTS: <br />om <br />- <br />yOAd�tt� CuJA1sw <br />F� pE.P�11A <br />ACCEPTED BY: -ril UL -1 <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: iA (.(- <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: q <br />?I E: <br />Fee Amount: Amount Paid <br />16 C) Payment Date <br />2 <br />Payment Type- 5 <br />invoice # <br />.Ceek#'�FyO <br />j 31)33 <br />Received By: <br />EHD 46-02-025 SR FORM (Golders Rod) <br />REVISED 11/17120D3 <br />