Laserfiche WebLink
SAN JOAQUI �-OUNTY ENVIRONMENTAL HEALTF.�PARTMENT BCE#tooso <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Costco Wholesale, c/o Barghausen Consulting Engineers, Inc. <br /> FACILITY NAME <br /> Costco Retail Fueling Facility Location No. 658 <br /> SITE ADDRESS <br /> 3250 West I Grantline Road Tracy 95377 <br /> Street Number i I n 5 zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18215 72nd Avenue South <br /> Street Number Sb I Name <br /> CITY Kent STATE WA zip 98032 <br /> PHONE#I E�' APN# LAND USE APPLICATION# <br /> ( 425) 656-7430 238-600-06 N/A <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ RVICE REQUESTO <br /> REQUESTOR <br /> Dennis Bock CHECKN BILLING ADDRESS13 <br /> BUSINESS NAME Costco Wholesale PHONE# EXT' <br /> 425 313-8100 <br /> HOME or MAILING ADDRESS 999 Lake Drive FAX# <br /> ( ) <br /> CITY Issaquah STATE Wa zip 98027 <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,St ndards,STATE an S. <br /> APPLICANT'S SIGNATURE: Dennis Bock DATE- 04/08/09 r_ <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ I�AGLL <br /> IfAPPL/CANT is not the BILLING 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. <br /> TYPE OF SERVICE REQUESTED: Plan check and permit issuance for PLLD and line split PAYMENT <br /> COMMENTS: <br /> APR 15 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE MDATE: O <br /> ASSIGNED TO: EMPLOYEE#: 2— DATE: <br /> Date Service Completed (if already co Ieted): SERVICE CODE: PIE' <br /> JOE I <br /> Fee Amount: �S Amount Paid 3` S Payment Date L- 15/0 <br /> Payment Type Invoice# Check# Received By: \ r— - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 10050.004-pdtdoc <br />