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SAN JOAQUI]yf�OUNTY ENVIRONMENTAL HEALTi PARTMENT <br /> SERVICE REQUEST BCE#10199 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fueling Facility ��bdc 51040 0tt/77 <br /> OWNER/OPERATOR <br /> Costco Wholesale CHECK if BILLING ADDRESS <br /> FACILITY NAME Costco Gasoline Loc. No. 38 <br /> SITE ADDRESS 1616 East Hammer Lane Stockton 95210 <br /> Street Number Direction Street Name Ci Zip e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 999 Lake Drive <br /> Street Number Street Name <br /> CITY Issaquah STATE WA ZIP 98027 <br /> PHONE#11 E'T APN# LAND USE APPLICATION# <br /> ( 425 ) 313-8100 094-280-11 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR TBD <br /> BARGHAUSEN CONSULTING ENGINEERS INC CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> 18215 72ND AVENUE SOUTH 425 251-6222 <br /> HOME or MAILING ADDRESS FAX# <br /> KENT, WA 98032 ( ) <br /> CITY STATE ZIP <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 /> COUNT Y Ordinance Coder,Standards�-,S-TAA�'II and FEDERAL laws./ <br /> APPLICANT'S SIGNATURE: DATEE: 11/12/2010 <br /> PROPERTY/BUSINESSOWNERa OPERATOR/MANAGER ❑ Ort{ERArrnonrzEoAGENTX Alexia Inigues, Project <br /> IfAPPLICAN7'ir not the BtLLINGPAH7'Y proof of authorization to sign is required Planner TiPfe <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 soonas it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 'CISH" /jE7./�D FiT PAYM p <br /> COMMENTS: <br /> NOV 18 2010 <br /> SANE FtONME�EMT <br /> HF..At-TI'I DEPS <br /> ACCEPTED BY: EMPLOYEE#: �✓la 4 DATE: f I f CI 10 <br /> ASSIGNED TO: ,Ji is EMPLOYEE#: 61131& DATE: (/ 16 �D <br /> Date Service Completed (if(ifralready completed): SERVICE CODE: I-/ d PIE: 808 <br /> Fee Amount: /qp Amount Paid Payment Date <br /> rG <br /> Payment Type L� Invoice# Check# �3 O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />