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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail <br />FACILITY ID # <br />E 3 1 <br />SERVICE REQUEST # <br />5Røø '?5O9 <br />OWNER / OPERATOR Costco Wholesale Corporation CHECK if BILLING ADDRESS <br />FACILnY NAME Costco Wholesale <br />SITE ADDRESS 3250 <br />Street Number <br />W <br />Direction <br />Grant Line Road <br />Street Name <br />Tracy <br />City <br />95377 <br />ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 999 <br />Street Number <br />Lake Dr <br />Street Name <br />CITY Issaquah STATE WA ZIP 98027 <br />PHONE #1 Exr. <br />( 425)313-6422 <br />APN # <br />23860006 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT if LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR Rory Fitzpatrick CHECK if BILLING ADDRESS <br />BUSINESS NAME MG2 Corporation pH9,,, 962-6546k <br />( Llig) <br />Err. <br />HOME or MAILING ADDRESS 1101 Second Ave, Ste 100 FAX # <br />( ) <br />CITY Seattle STATE WA zip 98101 <br />DULLING 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 <br />or 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 d IERAL law A...... <br />PROPERTY / BUSINESS OWNER!: OPERATOR / MAN ER 0 OTHER AUTHORIZED AGENT El Mostafa Ahanchi - Authorized <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Agent of Costco Wholesale <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />rovided to me or my representative. _ , <br />GA CI 4 — \- ° rou P .474-1411-0 7‘ i eett t -, TYPE OF SERVICE REQUESTED: Health Plan Review V , <br />COMMENTS: .e, 2-ce (-vrtil <br />, E <br /> RECEll <br />SEP 21 <br />A % JOAQUIN CI <br />I NVIRONMEN <br />I[ n LTH DEM RI <br />ACCEPTED BY: Ci.v.\4_ ,,. 6.z.; ( 0 EMPLOYEE #: DATE: <br />''-:/--ZZ <br />ASSIGNED TO: 1.--"( Vt. (7m.".e EMPLOYEE #: DATE: q <br />Date Service Completed (if already completed): SERvICE CODE: S" 1_3, P/ E: (0)0 <br />Fee Amount: 4 ._ Amount Paid 1,(66 ......_ Payment Date Z 21) 2-2-- <br />Payment Type Ak Invoice # 906 # 15 62 35- 3q? Received By: AP( <br />APPLICANT'S SIGNATURE: DATE: I <br />NT <br />ED <br />2022 <br />UNTY <br />AL <br />ENT. <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003