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SAN JOAQU- "OUNTY ENVIRONMENTAL HEAL— nEPARTMENT 10056 <br /> SERVICE REQUEST J Fuel Additive <br /> Type of Business or Property FA ILITY D# SERVICE REQUEST# <br /> Costco Gasoline [S p S��0� �' �S <br /> OWNER/OPERATOR <br /> Costco Wholesale,Attention: Licensing CHECK if BILLING ADDRESS❑✓ <br /> FACILITY NAME <br /> Costco Gasoline(Loc.No.658) <br /> SITE ADDRESS 3250 West Grant Line Road Tracy 95377 <br /> Street Number Direction Street Name C zi Code <br /> HOME or MAILING ADDRESS IN Different from Site Address) <br /> P.O. Box 35005 Street Number Street Name <br /> CITY STATE ZIP <br /> Seattle Washin ton 98124 <br /> PHONE#1 EM. APN# LAND USE APPLICATION# <br /> ( 425 ) 313-8100 238-600-06 N/A <br /> PHONER Em. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inigues, Project Planner CHECKIf BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT <br /> Barghausen Consulting Engineers,Inc. 425 1 251-6222 <br /> HOME or MAILING ADDRESS FAX# <br /> 18215-72nd Avenue South (425 ) 251-8782 <br /> CmKent WashlnT ton LP 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 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 <br /> E an FE laws. I 1 <br /> APPLICANT'S SIGNATURE: DATE: l l I�-- <br /> PROPERTY/BUSEWSS OWNER OPERATOR/ AGE ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANTis not the BILLING PAR r roo of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATI en 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 ENvntoNMENTAL 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 REouESTED:Fuel Additive Equipment and Tank Installation PAYMENT <br /> COMMENTS: RECEIVED <br /> NOV 2 6 2012 <br /> SAN JOAQUIN COUMY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: - �R, .N EMPLOYEE#: � T DATE: <br /> ASSIGNED TO: �D n. I EMPLOYEE#: go DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 031 PIE:2303 <br /> Fee Amount: O n Amount Paid a Payment Date I(T2 ?� <br /> Payment Type Invoice# Check# Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />