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• SERVICE REQUEST • Type of Business or Property Facility ID 9 Service Requ sy�� Retail Gasoline - C Store #32190 —7 � / J7 fes Owner/ Operator 7 -Eleven Inc. Check if Billing Address ❑ Facility name: 7 -Eleven #32190 site address 4943 Business Name f South State Route 99 e° r Iv Sacramento Equipment Maintenance Company, Inc. (Wo #126686) ( 916 ) 925-2716 Street Number direction street name Stockton 95602 Date: s l-!; Lej Assigned to: ^/A-( 0 �- Employee t:-`.�I+-�(p7 ZJ city zip code Home or Mailing Address (if different form site address) Attn: Gasoline Accounting - P.O. Box 711 City Dallas State Texas Zip 75204 Phone #1800-828-0711 &t. APN# 1-71 _ 3/ o _ c/ Land Use Application # Phone #2 Ext. BOIS District Location Codes / BILLING ACKNOWLEDGMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVI PONMEWAL HF ALT DEPAN ENr 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�ll� application and that a work to be performed will be done in accordance with all s... uoeou,. c..., Ordinance Codes, Standard; sTAr and FEDEruL laws. \ I J ( r \ Applicant Signature: Date: Property / Business Owner ❑ Operator/ Manager V Other Authorized Agent ■ President of Sacramento Equipment Maintenance Company Inc If Applicant Is r dt the Billing Party, proof of authorization to sign is requlrctl Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 information to the s,, Joeou,. co, Pueuc 11 a1i E.y„,o.nE.rAL D..Eio. as soon as it is available and at the same time it is provided to me or my representative. r C T -4-ac 'T.a r, r / T Type of Service Requested: Furnish necessary material & labor to repair/ replace #400988932 FE Petro check valve and/or #848480-001 Veeder-Root Pressure Line Leak Detector (PLLD) on (91)Chevron Premuim Requestor. Linda Steiger Comments:ZZ E/VED Check if Billing Address ■ Business Name Phone # Sacramento Equipment Maintenance Company, Inc. (Wo #126686) ( 916 ) 925-2716 Home or Mailing Address Fax # 2533 Connie Drive (916)925-2816 Sacramento, CA 95815 Date: s l-!; Lej Assigned to: ^/A-( 0 �- Employee t:-`.�I+-�(p7 ZJ BILLING ACKNOWLEDGMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVI PONMEWAL HF ALT DEPAN ENr 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�ll� application and that a work to be performed will be done in accordance with all s... uoeou,. c..., Ordinance Codes, Standard; sTAr and FEDEruL laws. \ I J ( r \ Applicant Signature: Date: Property / Business Owner ❑ Operator/ Manager V Other Authorized Agent ■ President of Sacramento Equipment Maintenance Company Inc If Applicant Is r dt the Billing Party, proof of authorization to sign is requlrctl Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 information to the s,, Joeou,. co, Pueuc 11 a1i E.y„,o.nE.rAL D..Eio. as soon as it is available and at the same time it is provided to me or my representative. r C T -4-ac 'T.a r, r / T Type of Service Requested: Furnish necessary material & labor to repair/ replace #400988932 FE Petro check valve and/or #848480-001 Veeder-Root Pressure Line Leak Detector (PLLD) on (91)Chevron Premuim pAy Comments:ZZ E/VED AUG 15 20`01 %11-T H EPgq Z NT Approvedby: OL-IVEt K' Employee#: Date: s l-!; Lej Assigned to: ^/A-( 0 �- Employee t:-`.�I+-�(p7 ZJ Date: cl L S ol-7 Date Service Completed (if already completed): Service Code: p / E:3 G2 Fee Amount: Amount paid: iii , U lJ payment Date: 15 (j 1 Payment Type Invoice # Check # S L� Received By: EHD 48-02-025 (Revised 11/17/2003) v:\ county \ san joaquin \ env \ forms \ permits \ repairsl