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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERACE REQUEST# <br /> Fueling Facility F/f 00/3 C'a ' 4C VAUAiV 0c� 2, <br /> OWNER I OPERATOR <br /> Costco Wholesale Corporation CHECK If BILLING ADD RESS <br /> ❑ <br /> FACILITY NAME Costco 658 <br /> SITE ADDRESS 1 3250 W Grantline Rd. Tracy 95304 <br /> 3250 Street Number pirection Street Name city ZID Cade <br /> HOME Of MAILING AoDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (209) 834-1247 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> RequEsroR <br /> Bruno Espinoza-Janes Covey Group, Inc. CHECKIf BILLING ADDRESS <br /> BUSINEss NAME: Jones Covey Group, Inc. PHONE# E:T. <br /> 909 543-8904 <br /> HOME Or MAILING ADDRESS 9595 Lucas Ranch Road#100 FAX# <br /> f 9091 484-0300 <br /> CITY Rancho Cucamonga STATE CA ZIP91730 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: - pgFE; 10/27/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR]MANAGER ❑ OTHER AUTHORIZED AGENT N ,Jones Covey Group-Permitting <br /> If APPLICANT is not the B)t_ ING 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 assessmentPAY � <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prOviRfEi gVo <br /> my representative. AIAlit <br /> TYPE OF SERVICE REQUESTED: ST ;ft• 2 <br /> 0nr2r1rrp c:obNT <br /> COMMENTS: irr:AN+rte EPh i 1LN1 <br /> On 10/10/2022 Replaced a like for like Defender Series Drop Tube located on Tank 2 878. Conducted 201.3 <br /> Static Pressure Performance Test and Drop Tube integrity Test. Both tests passed with no issues found. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: e rV Pr"-t-0 EMPLOYEE#: DATE: f f <br /> Date Service Completed (if already completed): ! '02� SERVWCEC00E: — G�� PIE: <br /> Fee Amount: Amount Paid 3 Payment Date <br /> Payment Type Invoice# Check# 11�!J Received By: <br /> �/}�G(" -/-0 � 2 5� � �� ,r ilia y-z- 0 <br /> EHD 48-02-025 1 4�" SR D (Golden Rod) ,J <br /> 07/17/08 /�J f l � (1L�C� 1 S C�7Z <br /> o '*7 11` ' ALL <br />