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SERVICE REQUEST <br />Type of Business or Property <br />Gasoline - C Store <br />Business Name <br />Sacramento Equipment Maintenance Company, Inc. (Wo #124679) <br />Facility ID#Request <br />#19976 <br />6 <br /># <br />rvRetail <br />k;e�04(fz'&O- <br />OwnerIt Operator 7 -Eleven Inc. <br />I`.. ::: <br />RECCE b /ED <br />HL -C ! VE -E-7 <br />Billing Party J <br />Facility name: 7 -Eleven #17647 <br />site address 1399 <br />Street Number <br />direction <br />North Main Street <br />street name <br />Inspectors Signature: <br />-------- <br />type <br />suite# <br />Mailing Address (if different form site address) <br />P.O. Box 711 <br />Employee#: j� Date: <br />Assigned to: <br />City Dallas <br />State Texas Zip 75204 <br />Date Service Completed (if already completed): <br />Phone #1800-828-0711 Ext. <br />I Service Code: <br />APN# <br />Land Use Application # <br />Fee Amount: <br />Phone #2 Ext. <br />(� <br />Payment Date: U t� <br />BOS District <br />Location Codes <br />Invoice # <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor: Linda Steiger Billing Party ■ <br />Business Name <br />Sacramento Equipment Maintenance Company, Inc. (Wo #124679) <br />Phone # <br />( 916 ) 925-2716 <br />Mailing Address <br />2533 Connie Drive <br />Sacramento, CA 95815 <br />Fax # <br />(916)925-2816 <br />BILLING ACKNOWLEDGMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific PUBLIC HEALTH <br />SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />I also certify that I have ep ed thI appl <br />laws. <br />Applicant <br />the work to be performed will be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes, Standard$ STATE and FEDERAL <br />Date: <br />Property / Business Owner ❑ Operator / Manager V Other Authorized Agent ■ President of Sacramento Equipment Maintenance Company, Inc. <br />If 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 site address, hereby authorize the release of any and all <br />results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH ENVIRONMENTAL DIVISION as soon as It Is available and at the same time <br />it is provided to me or my representative. <br />Type of Service Requested:Furnish necessary material & labor to replace the 91 octane fill bucket <br />Comments: �i�/fi t-% i/✓f✓LC� <br />' �1 <br />J`-r�(,� l/� C tj Sly �•Y `0 v/ <br />; r i� ENT <br />I`.. ::: <br />RECCE b /ED <br />HL -C ! VE -E-7 <br />SAN JOAQUIN COUNTY SAP: JOAOUINJ COUNTY <br />Inspectors Signature: <br />Contractors Signature: ENVIRONMENTAL <br />H <br />ENVIRONMENTAL <br />Tri DEPARTMENT <br />Approved by: <br />Employee#: j� Date: <br />Assigned to: <br />Employee#: <br />Date: <br />Date Service Completed (if already completed): <br />I Service Code: <br />P / E: <br />Fee Amount: <br />Amount Paid: g 5 , d <br />(� <br />Payment Date: U t� <br />Payment Type V S <br />Invoice # <br />Check # 111I 4 D 1 O -� �'I, U) <br />I Received By: <br />U <br />v:\ county \ san joaquin \ env \ forms \ permits \ repairsl 9 4 b a 0 _'t 10 0 U JL-- <br />