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SAN JOAQI.�%WCOUNTY ENVIRONMENT.AI,HEALThwdEPARTMENT <br /> SERVICE REQUEST Retrofit <br /> Type of Business or Property �FA�CIL TY ID# SERVICE REQUEST# <br /> Costco Gasoline T V U��19 v �-R 0o (p(p (o <br /> OWNER/OPERATOR <br /> Costco Wholesale.Attention: Licensing CHECK if BILLING ADDRESS <br /> FACILITY NAME Costco Gasoline(Loc.No.658) <br /> SITE ADDRESS 3250 West Grant Line Road Tracy 95377 <br /> Reek Number 1 04009. 1 Sheet N me City ZIP Code <br /> HONE Or MAILING ADDRESS (If DfRerent from Site Address) <br /> P.O. Box 35005 Si (Number Street Nam <br /> CITY STATE ZIP <br /> Seattle ashingion 98124 <br /> PHDNE#1 Err, APN# LAND USE APPLICATION It <br /> ( 425 ) 313-8100 238-600-06 NIA <br /> PHONE 02 EXT. BC1S DISTRICT LOCATION CODE <br /> 1 1 <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REOUESTOR <br /> Alexia Inigues, Project Planner CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Barghausen Consulting Engineers, Inc. 1425 1 251-6222 <br /> HOME Or MAILING ADDRESS FA%# <br /> 18215-72nd Avenue South (425 ) 251.8782 <br /> CITY Kent WasshitnEon ZIP 98032 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site andiOr project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated Willi this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance With all SAN JO.AQUIN <br /> COUNTY Ordinaure Codes,Standards,STATE and F14DERAI. •ws. <br /> APPLICANT'S SIGNATURE: /s p Y O� i DA'#7r�: ��,�� <br /> PROPERTY f RN R <br /> t.SINESS ON ER Z OPERATOR I NIANAG O OTHER AtITHORIZED AC ENT Sd <br /> TfAtwi;( .I,VT iS rrul the Brctavc PAer).proti ofae lhorizalion to s+is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, L 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 environmentallsile asseS.vtnenl <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same line it Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Retrofit Existing Tanks for Fuel Additive Installation <br /> COMMENTS: <br /> RECEIVE <br /> NOV 21 2012 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAIL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 198PIE:2308 <br /> Fee Amount: i Amount Paid '�j�. Payment Date <br /> Payment Type Invoice# Check#170T Received By: <br /> EHD 48-02-025 SR rORM(Golden Rod) <br /> REVISED 11/1712003 <br />