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DocuSign Envelope ID:21`173BE3-D39C-47D3-A993-65B9F76377E9 <br /> .TAN JiJAUUIN I.UUN 1 Y CNvIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST �� ex)233 2 ,3 <br /> Type of Business or Propertyf- FACILITY ID# SERVICE REQUEST# <br /> Costco Gasoline(Loc.No,038) FA0024496 An A0 60 <br /> OWNER I OPERATOR <br /> Costco Wholesale,cla Barghausen Consulting Engineers, Inc. C14ECK if BILLING <br /> AIWJ <br /> FACILITY NAME <br /> Costco Gasoline(Loc. No.038? <br /> SITE ADDRESS <br /> 1630 East Hammer Lane Stockton 95210 <br /> street Number Direction Street Name Cit Z!p Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 0/0 18215 72nd Street Number Ave S. Street Name <br /> CITY STATE zip <br /> Kent WA 98032 <br /> PHONE41 EXT• APN# LAND USE APPLICATION# <br /> (425 ) 251-6222 094-280-13 NIA <br /> PHONE#2 EXT �FBOS DISTRICT LOCATION CODE <br /> ( ) NIA NIA <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQuESTOR <br /> M.Alexia Inlgues,Authorized Agent CHECK if BILLING ADDRESS kN.J <br /> BUSINEss NAME PHONE# EXT. <br /> Barghausen Consulting Engineers, Inc. 425 ) 251-6222 <br /> HOME or MAILING ADDRESS FAX# <br /> 18215 72nd ave S. (425 ) 251-8782 <br /> CITY Kent STATE WA ZIP 98032 <br /> BILLING. 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 or <br /> 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 /> COUNTY Ordinance Codes, Standards, STATE and -EwAL Laws. <br /> FZy';,- <br /> �gned y: <br /> APPLICANT'S SIGNATURE: �q� DATE: 2/9/2021 <br /> PROPERTY I BUSINESS OWNER 11 OPERATOR WFAX9eR`l.._I OTHER AUTHORIZED AGENT ® Authorized Agent of Owner <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign 1s required TiiCe <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 andlor environmental/site assessment information <br /> to the SAN,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED. Removal of Healy GAS and Installation of ARID Permeator and associated equipment 1/1S-7 <br /> —12le//(J <br /> COMMENTS: <br /> ACCEPTED BY: n{�hi /� ,� EMPLOYEE#: DATE: a <br /> ASSIGNED TO: /a 9 Q //C, �CrT EMPLOYEE#: DATE; /aCPZ �� <br /> Date Service Completed (if already completed): SERVICE CODE; lqg P I E: <br /> Fee Amount'. 4 <br /> C511 p . Q Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EH D 48-02-025 ��7 /�-�� e__L � �" /�^ � � r����164�J?etl RM(Golden Roc{) <br /> 07/17/08 <br />