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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gasoline Station r � l 7 � � SRmm 8� 1�3 <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS ❑ <br /> Costco Wholesale <br /> FACILITY NAME Costco Gasoline ( Loc . No . 1031 ) <br /> 95337 <br /> SITE ADDRESSF. Manteca <br /> 2440 Street Number Direction Street Name cityZiCode <br /> Daniels Street <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18215 72nd Avenue South <br /> clo Barghausen Consulting Engineers , Inc. Street Number Street Name <br /> STATE Zip <br /> CITY Kent WA 98032 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 425 ) 251 - 6222 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Bar hausen Consulting Engineers , Inc . <br /> PHONE # Ems' <br /> BUSINESS NAME <br /> Costco Wholesale c/o Bar hausen Consulting Engineers , Inc . 14251251 - 6222 <br /> HOME or MAILING ADDRESS FAX # <br /> 18215 72nd Avenue South ( ) <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 /> 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 : 9/5/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Authorized Agent <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 /> RE <br /> TYPE OF SERVICE REQUESTED : � � A( JrC+ t , 1 r �' O r f I(M Chi � CErVE. ) <br /> COMMENTS : EP 1023 <br /> S" JOAQUIN <br /> ENVIRONCOUNTY <br /> n,ENTAL <br /> HEALTH DEPARiRIgNi <br /> ACCEPTED BY: p v���� EMPLOYEE # : DATE: 2 5 <br /> ASSIGNED TO : " EMPLOYEE M DATE: <br /> I <br /> Date Service Completed (if already completed ) : SERVICE CODE: lgP -24je PIE : 2301 <br /> Fee Amount: . c' �' Amount Paid Payment Date <br /> Payment Type Invoice # Check # 2 Received By : <br /> EHD 4&02-025 SR FORM (Golden Rod ) I <br /> 07/17/08 <br />