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i Costco Fuel Facility #1091 / Our Job No. 14573.11 ❑ New Facility Existing Facility Costco Fuel Facility #1091 / Our Job No. '14573.11 (needs SR#) San Joaquin County Environmental Health Department Apphication Form Facility Name Costco Fuel Facility (Loc. 1091 ) Site Address City State ZIP 2680 Reynolds Ranch Parkway Lodi CA 95240 APN Supervisor District 058-650-14 Tax Rate Area 001-001 Type of Service ❑Application for ❑ Consultation ❑ Change of Owner ElRepairs or Remodel Other Requested Operating Permit UST Removal Comments q'sr aQ M Ov-al If mobile food truck or License Plate Number u • t VIN J` pumper truck N/A N/A Contact Types 0 Billing Party ❑ Facility Owner ® Facility Contact ❑ Property Owner ® Contractor ® Requestor required Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner QQ OM4 or ❑Architect First Name Alexia Inigues Last name If contra Mr, indicate type and license number Address City State ZIP 18215 72nd Avenue South Kent WA 9 j r` Phone Phone Email , "U19 (425) 251-6222 N/A costco@barghaus n.com � i . ,.� :.., �r ❑ Billing Party ❑ Facility Owner Facility Contact El Property Owner ❑ Contractor ❑ r,4wl ct! JJryry 202 First Name Last name Alexia Ini UE;S If contractor, indicate type �� ber g RWRo P0 - ry Address City State 18215 72nd Avenue South Kent WA "WHO � q Phone Phone Email (425) 251-6222 costco@barghaus n.com ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑Architect First Name Last name If contractor, indicate type and license number Walt Friesen A, C21, C10, B, C61/D40, Haz, C57#30034 Address City State ZIP 8281 Commonwealth Avenue Buena Park CA 90621 Phone I Phone Email (714) 826-0352 pell (951) 312-4399 wfriesen@wpinc.com 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. I also certify that I have prepared this application and that thew r�e performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. t APPLICANT'S SIGNATURE: �k DATE: 4/1 4/2026 ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER 14 OTHER AUTHORIZED AGENT Manager, Authorized Agent Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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,geotechnlcal 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, Accepted By Assigned To t^ Linked FA ID E V AF i ' rnaf i Z, VA00204-51 Record Number Date I PE ��^ Fee �� ^ �b 7 ❑ Cash ❑ Check N Confirmation 4 / Payment 1 - 7Received By Rev 07/10/2024