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y� / n/11 <br /> SAN JOAQU�011 ENVIRONMFNTAI, HF,ALTI1 UF.PARTMENT <br /> SERVICE REQUEST Fuel Addible <br /> Type of Business or Property FACILITY ID 0 SERVICE REQUEST# <br /> Costco Gasoline 0 S S Ploo (,o(o 145 <br /> OWNER I OPERATOR <br /> Costco Wholesale,Attention: Licensing CHECK if BILLING ADDRESS <br /> FACIUTY NAME Costco Gasoline(Loc. No. 38) <br /> SITE ADDRESS 1616 East Hammer Lane Stockton 95210 <br /> Street Number I Dimction I Street Name City BeCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 35005 street Name <br /> CRY STATE ZIP <br /> Seattle Washin ton 98124 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( 425 ) 313-8100 094-280-13 <br /> PHONE 92 EXT, BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR ! SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inigues, Project Planner CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Barghausen Consulting Engineers, Inc. 425 1 251-6222 <br /> HOME or MAILING ADDRESS FAIL# <br /> 18215-72nd Avenue South (425 ) 251-8782 <br /> CITY Kent WasVinT ton Zip 98032 <br /> RILLINC ACKNOWLEDGEMENT: 1, 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,SrandardT, STATE:and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: i ' DATE: (� <br /> PROPERTY/BUSINESS OUALRO OPERATOR/MA AU.E OTHER AUTHORIZED AGENT® Director of Real Estate Dev. <br /> IJ AIwII(AVT JS Jrof the Bllll• (iYarsrT. an >jauthorization to sign is required rnlr <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 LNVIRONMFNT.AL HrAi-TH 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:Fuel Additive Equipment and Tank Installation A <br /> COMMENTS: R <br /> ��V 19 202 <br /> ORIGINAL p �Cou <br /> SW rEO03-ZEpllKtiµM <br /> ACCEPTED BY: Er �—>At--K,- EMPLOYEE#: DATE: <br /> ASSIGNED TO: Gf&L, EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: 1 P I E:2303 <br /> Fee Amount: / L6---7Amount PaldS 1 Oo0.00 payment Date (( 1 / <br /> Payment Type I/ Invoice# Chockill 5 Received By: <br /> EHD 4"2-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />