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SAN JOAQU%COUNTY ENVIRONMENTAL HEALTH',&tPARTMENT <br /> SERVICE REQUEST Feel Additive <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Costco Gasoline <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> Costco Wholesale,Attention: Licensing <br /> FACILITY NAME <br /> Costco Gasoline(Loc.No.38) <br /> SITE ADDRESS 1630 East Hammer Lane Stockton 95210 <br /> Street Number Direction I Street Name CIN Zi Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O.Box 35005 Stmt Number Street Name <br /> CITY STATE ZIP <br /> Seattle Washington 98124 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 425 1313-8100 094-280-13 <br /> PHONEY EXr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECKIT BILDNG DRE <br /> Alexia Inigues, Project Planner <br /> BUSINESS NAME PHONE# ' <br /> Barghausen Consulting Engineers, Inc. 425 1 251-6222 <br /> HOME or MAILING ADDRESS FAX# <br /> 18215-72nd Avenue South (425 ) 251-8782 <br /> Crry Kent WaSNinTton ZIP 98032 <br /> BH,LING 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 a plication and that the wyr1, o be erformed will be done in accordance with all SAN JOAQUI N <br /> COUNTY Ordinance Codes,Stand s, TE and F DE I< Gs. <br /> APPLICANT'S SIGNATURE: DATE: 2 1 <br /> PROPERTY/BDSDVESS OWNER[] OPERATOR/MAN AC ❑ O AUTHomzED AGENT 0 Director of Real Estate Development <br /> IJAPPLICANT is nat the BILLING PAR7Y. roofoj'authori tioIto. <br /> to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATI licable,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 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:Fuel Additive Equipment and Tank Installation <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (R already completed): SERVICE CODE: 031 PIE:2303 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />