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SAN JOAQubwCOUNTY ENVIRONMENTAL HEALTIMO'FPARTMENT <br /> SERVICE REQUEST Retrofit <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 /> FAclurrNAME Costco Gasoline(Loc. No.38) <br /> SITE ADDRESS 1630 East Hammer Lane Stockton 95210 <br /> street Number I DIeWti. I Sbyet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 35005 Si MNumber Street Name <br /> CITY STATE ZIP <br /> Seattle Washin ton 98124 <br /> PHONE#fAPN# LAND USE APPLICATION# <br /> IF <br /> ( 425 1313-8100 094-280-13 <br /> PHONE#E BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inigues, Project Planner CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> Barghausen Consulting Engineers, Inc. 425 1 251-6222 <br /> HOME or MAILING ADDRESS FAX If <br /> 18215-72nd Avenue South77 (425 ) 251-8782 <br /> Cm Kent Washin�on 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 application and that the work to be performed will be done in accordance with all SAN JOAQuiN <br /> COUN'T'Y Ordinance Codes,Standards,STATE and FEDE S. <br /> APPLICANT'S SIGNATURE: DATE: ( L 3 <br /> PROPERTY/BUSDQEss OWNER❑ OPERATORIM NAGER ❑ OTHER AUTHORIZED AGENT O Director of Real Estate Development <br /> If APPLICANT is not the BILLING PAK7y d au mrizadon to sign is required Tule <br /> AUTHORIZATION TO RELEASE INFORMATION: When 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 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 <br /> COMMENTS: <br /> FEB 2 7 2013 <br /> ENVACCEPTED BY: �� ` i�0 i-�tL7i) EMPLOYEE#: DATE: <br /> PER' <br /> ASSIGNED TO: _ EMPLOYEE III: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 198 P/E:2308 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 40-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />