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SAN JOAQUIN COUNTY ENVIRONMENTA HEA TH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Retail Gasoline Station \,Zmm8� 1 (02 OWNER / OPERATOR Costco Wholesale CHECK If BI INGADDRESS11 FACILITY NAME Costco Gasoline ( Loc . No . 658 ) SITE ADDRESS W Grant Line Road Tracy 95377 3250 Street Number Direction Street Name city Z113 Code HOME or MAILING ADDRESS (If Different from Site Address) 18215 72nd Avenue South c/o Barghausen Consulting Engineers , Inc . Street Number Street Name CITY STATE ZIP Kent WA 98032 PHONE #1 EXT. APN # AND USE APP [CATION # ( 425 ) 251 - 6222 PHONE #2 EXT. BOS DISTRICT OCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Barghausen Consulting Engineers , Inc . cHECKifBI ING ADDRESS BUSINESS NAME PHONE # EXT, Costco Wholesale c/o Bar hausen Consulting Engineers , Inc . 425 251 - 6222 HOME Or MAI ING ADDRESS FAX # 18215 72nd Avenue South ( ) CITY Kent STATE WA zip 98032 BI ING ACKNOW EDGEMENT: I , the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards , STATE and FEDERAL laws . APP (CANT' S SIGNATURE : �—�" 1 DATE : 9/5/2023 PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Authorized Agent If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RE EASE INFORMATION : When applicable, 1 , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information 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 my representative . ', ,�,,` NT TYPE OF SERVICE REQUESTED : .USPF IRS,� / v �b t ,u / y/ C* - �l.� nRECEI ED COMMENTS: SEP 1 12023 SAN JOAQUIN C UNTY •T' ENVIRONMEIN TAL HEALTH DEPAR MENT ACCEPTED BY: s, EMP OYES M DATE: 5 of ASSIGNED TO : AIS 0 EMP OYEE M DATE: 2:!5 I Date Service Completed (if already completed ) : -- - SERVICE CODE : f, 2 d PIE, Fee Amount: 1*49/ � Amount Paid Payment Date Payment Type Invoice # Check # 1 l Z`� T Received By : i i EHD 48-02-025 SR FORM (Golden Rod ) 07/17/08