Laserfiche WebLink
Costco Loc . No . 38/ BCE# 10199 ( 6213 . 5 ) <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Members only Retail Gasoline Station , q S KCb m 8 � 8 7 8 <br /> OWNER / OPERATOR <br /> Costco Wholesale Corporation CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Costco Gasoline ( Loc . No . 38) <br /> SITE ADDRESS E Hammer Lane Stockton 95210 <br /> 1630 <br /> Street Number Direction Street Name cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18215 72nd Avenue South <br /> c/o Barghausen Consulting Engineers , Inc . <br /> Street Number Street Name <br /> CIT ATE STAATE ZIP <br /> K VWV 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 <br /> Aaron Ridill CHECK if BILLING ADDRESSO <br /> BUSINESS NAME PHONE # EXT• <br /> Wayne Perry 14 366 - 5983 <br /> HOME or MAILING ADDRESS FAX # <br /> 8281 Commonwealth Ave . ( ) <br /> CI Mena Park STATE CA ZIP 90621 <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 aws . <br /> APPLICANT' S SIGNATURE : DATE : 3/25/2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Authorized Aclent <br /> /f 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS providp(t f0 me or <br /> my representative . p L I"-a7 <br /> At <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : O <br /> After-The- Fact like for like sensor replacement . 3 MAR ? 9 20 <br /> 'Kew/ .4 q ,4 o" 9/,%) 2 � vi d �a.�7b�'7 S`J CIor4 ow 3// sF e NJ04 <br /> I�CJSTYIOlLf HFq � THRON41 Coo <br /> F <br /> � n o fi �ili�.fitrrl � pgR M� Ty <br /> ACCEPTED BY : ,(�/� �%7 GLJ EMPLOYEE M DATE : T <br /> / ` Z - 2 <br /> ASSIGNED TO : �/t i1�/J EMPLOYEE M DATE: 31.2 $ 12 <br /> Date Service Completed (if already completed) : 3C� SERVICE CODE: ✓ �211J' P / E: <br /> Fee Amount: 0 (/� • {- LfV) Amount Pal C� 7 a �� Payment Date 3 2� <br /> Payment TypeInvoice # Check # I 79 ,F6 3 n? 7 Received by, <br /> OEC D 48802-025 ,o /�� �j y��/ `/ ��Q� SR FORM (Golden Rod ) <br />