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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Properly <br />FACILITY ID q <br />SERVICE REQUEST <br />OWNER 1 OPERATOR <br />Costco Wholesale <br />CHEECKIfBILLUNGADDREss13 <br />F,,NAME Costco Wholesale Manteca, <br />CA <br />SITE ADDRESSDaniel St. <br />2440 SbW Nume.. streot Nam <br />Manteca <br />cl <br />195336 <br />HOME or MAILING ADDRESS Iff Different from Site Address) <br />Strut Number <br />-0111.9991— <br />CITY <br />STATE zip <br />PHONE tit ExT• APN # <br />l I <br />LAND USE Appur-ATRNI # <br />PHONE #2 <br />( i <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REGUESTOR <br />COMMENTS: <br />Isaac Anderson <br />CHECK If BILLING ADDRESS <br />BUSINEssNAME Alltech Petro Ca <br />ASSIGNED TO: <br />PHONE# fir' <br />DATE: <br />Date Service Completed (H already completed): <br />(209)532-7320 <br />HOME or MAILING ADDRESS P.O. BOX 4208 <br />FAX # <br />Payment Type <br />Invoice # <br />(209)533-2650 <br />CITY Sonora <br />STATE CA ZIP 95370 <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 />COUNTY Ordinance Codes, Standards, STATE and R L laws. <br />APPLICANT'S SIGNATURE: 190, DATE_ 08-2-2010 <br />PROPERTY 1 BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Service Technician <br />!f APPLICANT is not the BfLuNG PA, R7Y proof of authorizadon to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION- When applicable, 1, 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 />Orovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: NAA <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (H already completed): <br />SERVICE CODE: PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check S <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />