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SAN JOAQUIWCOUNTY ENVIRONMENTAL HEALTB-idEPARI HIEN <br /> SERVICE REQUEST BCE#10199 Retrofit <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Costco Gasoline l ©� Swtd ('0 ([ ) <br /> OWNER J OPERATOR <br /> Costco Wholesale, Attention: Licensing CHECK Ir BILLING ADDRESS ✓ <br /> FACILITY NAME <br /> Costco Gasoline(Loc.No.38) <br /> SITE ADDRESS 1616 1 East I Hammer Lane Stockton 95210 <br /> Street Number Dlraceon SVe Na. city by Co e <br /> HOME or MAILING ADDRESS (it Different from Site Address) <br /> RO. Box 35005 Sv«t Numbs N m <br /> CITY STATE zip <br /> Seattle Washin ton 98124 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 1 425 ) 313-6100 094-280-13 <br /> PHONE N2 ERT, BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inigues, Project Planner CHECK If BILLING ADDRESS <br /> PHONE# Ex, <br /> BUSINESS NAME _ <br /> Barghausen Consulting Engineers, Inc. 1425 1 251-6222 <br /> HOME or MAILING ADDRESS FAx# <br /> 18215-72nd Avenue South (425 ) 251-8782 <br /> CITY Kent Wa hlnT ton ZIP 98032 <br /> BILLING 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> OwN,flOi-dinanre Cndec,Slandardr,$TATE•nd FGD:RAI. ws. <br /> APPLICANT'S SIGNATURE: 07� DATE:' <br /> PRO VLRII /BI STNESS OWNER OPERATOR MANAG-5lOTHER AUTHORIZED ACENTO Director of Real Estate Dev. <br /> Ij Atwi u'I vT isnot the 81111yeY4871 proojejaurhorizallon to sign 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 andor environmentallsite 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: Retrofit Existing Tanks for Fuel Additive Installation PAWRENT <br /> COMMENTS: RECEIVED <br /> NOV 19 [012 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENI <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: G �1A EMPLOYEE DATE: /� <br /> Date Service Completed (if already completed): SERVICE CODE: 198 PIE'2308 <br /> Fee Amount: -7 S 1 Amount Paid Payment Date <br /> Payment Type Invoice# Check# �5 Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 7/2003 <br />