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• SERVICE REQUEST . <br /> -Type of Business or Property Facility ID /,/ p Service Request# <br /> Retail Gasoline-C Store 190 <br /> Owner/Operator 7-Eleven Inc. Check if Billing Address❑ <br /> Facility name: 7-Eleven #32190 <br /> site address 4943 South State Route 99 Stockton 95602 <br /> Street Number direction street name <br /> city zip code <br /> Home or Mailing Address(if different form site address) <br /> Attn:Gasoline Accounting-P.O. Box 711 <br /> City Dallas State Texas Zip 75204 <br /> Phone#1800-828-0711 Ext. APN# / ° L` Land Use Application# <br /> Phone#2 Ext. BOS District i Location Cdes <br /> CONTRACTOR/SERVICE REQUESTOR lJ <br /> Requestor: Linda Steiger Check if Billing Address■ <br /> Business Name Phone# <br /> Sacramento Equipment Maintenance Company,Inc. (Wo#123843) (916)925-2716 <br /> Home or Mailing Address Fax# <br /> 2533 Connie Drive (916)925-2816 <br /> Sacramento,CA 95815 <br /> BILLING ACKNOWLEDGMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> ENVIRONMENTAL HEALTH DEPART hourly charges associated with this project or activity will be billed to me or my business as identifed on this form. <br /> I also certify that I have prepare ap �ation and that t wo be performed w e done in accordance with all San Joaquin County Ordinance Codes,Standmds,State and Federal <br /> laws. <br /> Applicant signature: Date: <br /> Property/Business Owner Operator/Manager er Authorized Agent■ President of Sacramento Equipment Maintenance Company,Inc. <br /> If Applicant Is not the Billing:sirty 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 site address,hereby authorize the release of any and all <br /> results,geotechnical data and/or environmental/site assessment information t0 the San Joaquin County Public Health Environmental Division as soon as it is available and at the same time It Is <br /> provided to me or my representative. <br /> Type of service Requested: Furnish necessary material &labor to repair/ replace #400988932 FE Petro check valve and/or#848480-001 <br /> Veeder-Root Pressure Line Leak Detector(PLLD) on (89)Chevron Plus. <br /> Comments: PAYMENT <br /> RECEIVED <br /> SEP 14 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APP Y: Employee#: �73�1p Date: <br /> Assigned to: �U Employee#: Date: <br /> Date Service Completed(if already completed): service Code: C P/E: �3Og <br /> Fee Amount: Amount Paid: $ 'P-p'_'>c L) 0Payment Date: I a <br /> Payment Type Invoice# Check# q 3-731 lReceived By: <br /> EHD 48-02-025(Revised 11/17/2003) <br /> v:\county\son Joaquin\env env\forms\permits\repairsl <br />