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i <br /> SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST BCE #10050 . 11a <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CIO <br /> Gas Station FA0013810 C0352-+Z <br /> OWNER/OPERATOR <br /> CHECI<If BILLING ADDRESS <br /> Costco Wholesale <br /> FACILITY NAME <br /> Costco Gasoline Loc. No. 658 <br /> SITE ADDRESS 3250 West Grant Line Road Tracy 95377 <br /> Street Number Direction 5 ee Name City Z Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) p/i M <br /> P.O. Box 35005 Street Number Street Name ^I '►/�A <br /> CITY STATE ZIP ,Y <br /> Seattle WA 98124 �,VEo <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209)830-5340 23860006 CUP20-0003/419-0033 Sq IV 6 2422 <br /> PHONE#2 EXT. BOS DISTRICT LOCP/r�fC1 O CO <br /> (425)313-8100 T N�E RTM k <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> M. Alexia Inigues CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> Bar hausen Consulting Engineers, Inc. (425)251-6222 <br /> HOME or MAILING ADDRESS FAX# <br /> 18215 72nd Avenue South (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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: "�-�—E L--=--- _ DATE: May 5, 2022 <br /> PROPERTY I 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, 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: ��S j� las <br /> C/{ <br /> COMMENTS: <br /> s�oo ��Coo3 Cre-ftV17f0le <br /> ACCEPTED BY: � /.��� EMPLOYEE#: DATE: (P Z2 <br /> ASSIGNED TO: t0 EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: IqZ P 1 E: ,;5O2 <br /> Fee Amount: 4`7� -O � Amount Paid l�s/ 0O Payment Date <br /> • <br /> Payment Type j Invoice# Check# 1 32_?-7771 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />