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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> i SERVICE REQUEST <br /> Type of Business or Property FACILITY(D# SERVICE REQUEST# <br /> Costco Wholesale (Loc. No. 658) ��- �� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> Costco Gasoline (Loc. No. 658) <br /> FACILITY DAME <br /> Costco Gasoline(Loc. No. 658) <br /> SITE ADDRESS West Grantline Road Tracy 35' <br /> 7'7- <br /> 325'0 S[reetNumber Direction Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> P .O. BOX 35005 Street Number Street Name <br /> CITY STATE 198124 <br /> Seattle <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 425 ) 313-8100 C94-280-13 <br /> PHONE 92 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Alexia Inigues, Project Planner <br /> BUSINESS NAME PHONE# ExT' <br /> Barghausen Consulting Engineers, Inc. 425 251-6222 <br /> HOME or MAILING ADDRESS FAx# <br /> 18215 72nd Ave South (425 ) 251-8782 <br /> CITY Kent $_TAATE ZIP 98032 <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 DEPARTviENT 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 JOAQUTN <br /> COUNTY Ordinance Codes,Standards,STATE and FERE AL laws. 1 1 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Planner <br /> IfAPPLICANT 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 JOAQUTN COUNTY ENVTRONMENTAL 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: PAS <br /> COMMENTS: b8 <br /> C <br /> 1 � <br /> 'SA"a <br /> A A2418 <br /> Etil r I <br /> 77,ft <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �� EMPLOYEE M DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: (-7l P I E:,)?)O <br /> Fee Amount: i vv Amount Pa L0 7,0 Payment Date L7 <br /> Payment Type Invoice# Check# Q eceived By: <br /> EHD 48-02-G25 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />