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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID #ERVICE REQUEST # Fueling Facility FAOO'3 C' 0 BUSINess NAME: Jones Covey Group, Inc. �OA-NjjpU (� OWNER / OPERATOR Ems' 543-8904 HOME or MAILING ADDRESS 9595 Lucas Ranch Road #100 Costco Wholesale Corporation FAX # CHECK ifBILLINGADD RESS❑ FACILITY NAME Costco 858 Amount: e 4 Amount Paid ( 909) SITE ADDRESS I 1 3250 W Grantline Rd. Tracy Check # V) S 95304 3250 Street Numher Dirarti h Street Name city Zip Code HOME ❑r WAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #'I EXT. APN # LAND 115E APPLICATION # ( 209 ) 834-1247 PHONE #2 ExT. } 130S DISTRICT LOCATION CODE CONTRACTOR 1 SERVICE REQUESTOR REQuESTOR Bruno Espinoza - Jones Covey Group, Inc. CHECxif BILLING ADDRESS BUSINess NAME: Jones Covey Group, Inc. PHONE# 909 Ems' 543-8904 HOME or MAILING ADDRESS 9595 Lucas Ranch Road #100 FAX # Amount: e 4 Amount Paid ( 909) 484-0300 CITY Rancho Cucamonga STATE CA ZiP91730 BILLING ACKNOWLEDGEMENT: 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. APPLICANT'S SIGNATURE: DATE. 1 D�2712022 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT N Jones Covey Group - Permitting /f APPtiCANT is not the B)tLING PARTY, proof of author/zat/on to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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�{t to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it is proviREFOL" my representative. ein&, EHD FIs -02-026 07/17/08 TYPE OF SERVICE REQUESTED: �' it Fluv �norlrr� cauur COMMENTS: I rrALTj r of PA R f M L41 On 10/10/2022 Replaced a like for like Defender Series Drop Tutee located on Tank 2 87B. Canducted 201.3 Static Pressure Performance Test and Drop Tube integrity Test. Both tests passed with no issues found. ACCEPTED BY: n► EMPLOYEE#: DATE: ASSIGNED TO: / /]}may �r�� EMPLOYEE #: DATE: f Date Service Completed (if already completed): I ip 2� SERViCECODE: 2C7i P IE: � FL l s 22TV1, � 1S �gdo 1-3v 22 i11i�y6 y'Lr � Z E T?T SR ❑ (Golden Rod) Amount: e 4 Amount Paid 3 �� Payment Date ent Type Invoice # Check # V) S Received By: EHD FIs -02-026 07/17/08 TYPE OF SERVICE REQUESTED: �' it Fluv �norlrr� cauur COMMENTS: I rrALTj r of PA R f M L41 On 10/10/2022 Replaced a like for like Defender Series Drop Tutee located on Tank 2 87B. Canducted 201.3 Static Pressure Performance Test and Drop Tube integrity Test. Both tests passed with no issues found. ACCEPTED BY: n► EMPLOYEE#: DATE: ASSIGNED TO: / /]}may �r�� EMPLOYEE #: DATE: f Date Service Completed (if already completed): I ip 2� SERViCECODE: 2C7i P IE: � FL l s 22TV1, � 1S �gdo 1-3v 22 i11i�y6 y'Lr � Z E T?T SR ❑ (Golden Rod)