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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station FA0013810 S R 00 27 a 4 a <br /> OWNER / OPERATOR <br /> Costco Wholesale Corporation CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Costco Gasoline #658 <br /> SITE ADDRESS 1 3250 W Grantline Rd . Tracy 95304 <br /> 3250 Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address ) 999 Lake Dr . <br /> Street Number Street Name <br /> CITY Issaquah STATE WA ZIP 98027 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Rob Sills - Jones Covey Group , Inc . CHECK if BILLING ADDRESS <br /> BUSINESS NAME Jones Covey Group , Inc . PHONE # EXT• <br /> 714 975 - 4257 <br /> HOME or MAILING ADDRESS 9595 Lucas Ranch Road # 100 FAX # <br /> ( 909 ) 484- 0300 <br /> CITY Rancho Cucamonga STATE CA ZIP 91730 <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 FEDERAL laws . <br /> APPLICANT'S SIGNATURE : DATE : 9/21 /23 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Permits <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 /> t0 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 : u Srr /}/ (! <br /> COMMENTS : <br /> Surface repair of Bravo penetration fitting inside vent box sump to repair a secondary piping leak on the 87A Vent <br /> Line penetration fitting , inside the vent sump ( no excavation ) . Repair Bravo Epoxy Kit . <br /> ACCEPTED BY: r A )V �! EMPLOYEE # : DATE: <br /> ASSIGNED TO : I EMPLOYEE #: DATE: Z� <br /> Date Service Completed (if already completed ) : n SERVICE CODE : (?,2G�� P I E2 30F <br /> ✓ <br /> Fee Amount : 00 Amount Paid Payment Date `; <br /> Payment Type ' f ' Invoice # Check # R ceiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />