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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUESTT## <br /> Gas Station 194 0O/ - it <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS 13 <br /> Costco Wholesale <br /> FACILITY NAME <br /> Costco Gasoline ( Loc. No . 1031 ) <br /> SITE ADDRESS 2440 Daniels Street Manteca 95337 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P . O . Box 35005 Street Number Street Name <br /> CITY STATE ZIP <br /> Seattle WA 98124 <br /> PHONE #t EXTS APN # LAND USE APPLICATION # <br /> ( 425 ) 313-8100 24153001 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQU ESTO R CHECK if BILLING ADDRESS <br /> M . Alexia Ini ues <br /> BUSINESS NAME PHONE # EM' <br /> Bar hausen Consulting Engineers , Inc . ( 425 ) 251 -6222 7430 <br /> HOME or MAILING ADDRESS FAX # <br /> 18215 72nd Avenue South ( 42-1; 1251 -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 end/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 /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JonqulN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE : 1�� �— DATE : October 29 , 2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Authorized Agent for Costco Wholesale <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1 , 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 ijp�rpvided to me or <br /> my representative . �� <br /> TYPE OF SERVICE REQUESTED: S7 l ' <br /> COMMENTS: /VoY <br /> O <br /> NF <br /> L/0,4 Q0 0 <br /> A � TNpq/V �0/JV <br /> MFNT <br /> ACCEPTED BY: S f �� � EMPLOYEE #% DATE: Z <br /> ASSIGNED TO : `2 � EMPLOYEE #1 DATE: <br /> Date Service Completed (if already completed): SERVICE CoDE: 1�� — 2 G� S' P 1 E: Z 3 D �` <br /> Fee Amount : rJ� ew Amount Paid TSG i) D Payment Date <br /> Payment Type Invoice # Check # /33 %J(�;z,68 Rece ved By : <br /> EHD 48.02-026 SH FORM (Golden Rod ) <br /> 07/17/08 <br />