Laserfiche WebLink
DocuSign Envelope ID:2F173BE3-D39C-47D3-A993-65B9F76377E9 <br /> JAN JUAUUIN toUUN I Y r-NvIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Costco Gasoline(Loc. No.038) FA0024496 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> Costco Wholesale,c/o Barghausen Consulting Engineers, Inc. <br /> FACILITY NAME <br /> Costco Gasoline(Loc. No.038? <br /> SITE ADDRESS <br /> 1630 East Hammer Lane Stockton T95210 <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> c/0 18215 72nd Street Number Ave S. Street Name <br /> CITY STATE ZIP <br /> Kent WA 98032 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (425 ) 251-6222 094-280-13 N/A <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) N/A N/A <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> M.Alexia Inigues,Authorized Agent CHECK If BILLING ADDRESS X <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 /> 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 FEDF� AI laws. <br /> ocu igne y: <br /> APPLICANT'S SIGNATURE: DATE: 2/9/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR mANflazDpAW t4 3 OTHER AUTHORIZED AGENT ® Authorized Agent of Owner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Removal of Healy CAS and Installation of ARID Permeator and associated equipment <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />