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MEMO <br /> DocuSign Envelope ID:D1A5C26E-F962-0089-8 15075D5DF4C3 <br /> JAN JUANWOUIN'I Y ENVIRONMENTAL HEALTI•EPARTMENT <br /> SERVICE RE Costco Loc. No.038 <br /> UEST / <br /> Q Our Job No. 10199.19 <br /> Type of Business or Property FACILITY ID# <br /> --7— <br /> Type <br /> REQUEST#Costco Gasoline(Loc. No. 038) �(� � � T7SERVICE <br /> /Y�� /_ t/V.� <br /> OWNER/OPERATOR I I1 lf"U & <br /> Costco Wholesale, Attention: Licensing CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> Costco Gasoline(Loc. No. 038) <br /> SITE ADDRESS <br /> 1630 Street Street Name Fh�st Hammer Lane Stockton 952100 <br /> Number etlon CI <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> de <br /> P.O. Box 35005 <br /> Street Num Stmet N <br /> ame <br /> CITY STATE ZIP <br /> Seattle Washington 98124 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( 425 ) 313-8100 094-280-13 <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inigues, Project Planner CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ezr. <br /> Barghausen Consulting Engineers, Inc. 425 251-6222 <br /> HOME or MAILING ADDRESS FAX# <br /> C18215 72nd Avenue South g (425 )251-8�j782 <br /> Ty <br /> ITY <br /> Ke t Washln ton 98032 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/oI 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 /> I1 USIllml by: <br /> APPLICANT'S SIGNATURE:�t1/i4f �t(A DATE: 12/16/2016 <br /> PROPERTY/BUSINESS OWNER❑✓ �PWRY614?A4AN'AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tote <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: Installation of wireless dispenser sump and vent sensors PAYMEN RECEIVED' <br /> COMMENTS: <br /> OEC 19 2016 <br /> J JOAQUIN COUNTY <br /> NVIRONMENTAL <br /> TH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE, 1_ _ '(' ,I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if alread mpleted): SERVICE CODE: 198 P I E: 2308 <br /> Fee Amount: Amount Paid J <br /> ' I N c9 Payment Date / a 4 (b <br /> Payment Type Invoice# Check# <br /> / a ( Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />