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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gasoline FA0018721 7DQ00 8 <br /> OWNER / OPERATOR <br /> Costco Wholesale CHECK if BILLING ADDRESSO <br /> FACILITY NAME Costco Wholesale #1031 <br /> SITE ADDRESS 2440 Daniels Street Manteca 9533 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18215 72nd Avenue South <br /> Street Number Street Name <br /> CITY Kent STATE WA ZIP J8032 <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 425 ) 251 -6222 24153001 MPM 18 - 113 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Alexia Inigues CHECK if BILLING ADDRESS X <br /> BUSINESS NAME PHONE # Ext <br /> Costco Wholesale c/o Barghausen Consulting Engineers , Inc. 425 251 -6222 <br /> HOME or MAILING ADDRESS FAX # <br /> 18215 72nd Avenue South ( 425 ) 251 -8782 <br /> CITY Kent STATE WA 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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 /> COUNTY Ordinance Codes, Standards, STATE and FEDE L laws . <br /> APPLICANT' S SIGNATURE : DATE : J ff E <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required Title <br /> i <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same f I is provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : Ot <br /> Alk IV <br /> RrAfE/r <br /> ACCEPTED BY : EMPLOYEE # : DATE . <br /> ASSIGNED TO : �" <br /> e i t EMPLOYEE # : DATE ' <br /> ZY <br /> Date Service Completed (if already completed):' SERVICE CODE : ? ' ' PIE : > <br /> Fee Amount _ Amount Paid Payment Date k ; <br /> Payment Type Invoice # Check # x Received By y <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />