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�- -031 6:24.'7M;Secs'smento EMC 'v16 82s2816 = Zf A <br /> 0 <br /> SERVICE REQUEST <br /> Typo of Buslness or Property Nrl11 5a a Request# <br /> Retail Gasalhte-C Store V I� <br /> Owner/operator 7-Ekevren Inr.. Billing Party a <br /> Facility name: 7-JEle1ven 4114117 <br /> site address 2725 Country Club Lane <br /> Street Number d:recUon street name Lypc Suiten <br /> Mailing Address(U different form site address) <br /> P.O.Box 711 <br /> CW Dallas State Teras ap 752154 <br /> Phone*1800-828-011 Ext APNi� Lead UseAppllratlon s <br /> Phase 2 Ext DOS IaWCt Lacaton Codes <br /> CONTRACTOR SERVICE REQ UI~STDR <br /> frilling ParC><� <br /> Requester- Linda staiger <br /> Buslaes5 Name Phone# <br /> SacramenW Fqulpmum Maint mance Company,Ina (WG 8111468} (916)92S-2716 <br /> MaPing Addr� Fax# <br /> 2533 Connie Drive (918)925-28]6 <br /> Sacrimento,CA 45$15 <br /> BLUING Aq<NOWLEDGMENT:)r the ndersigned property or business owner,operator or authorized agent or same,acknowledge that all site andlor project aperdfic ovouc Hw-TH <br /> r,ERllce s rN"R.HXc T.r.He L;rH I hourly charoPs nssadated with this pro]e¢or actjVlry will be billed to me or my business as Ideneliled on this form. <br /> I also certify that I have prap' Is application and that rhe vrark to be performed All be done I accordance with all a——au.+.C.—G7Mf/nance Cadet Standaraiv,sT„E and FsesRni. <br /> laws r <br /> b� 2)-E 1 Yl l/1`> - 1"/n3 <br /> ApphMnt Slgnata,re: Date: <br /> property!Business owner Operator I Manager other Auldnerized Agent <br /> Ir Applicant(r;nor the ElOng Kirty proof or auftrimtlon tv%IV Is required TWe <br /> AUTHORIZATION TO RELFA5E INFORMATION-When dppNcable,I,the Domer or operamr of the property located at the above site addrese,hereby authorize tlTe release of any and all <br /> results,aeorechnlcl data and/or envlronmental/slta assessment Infvrmatlon to the;,..r.j��H co.,.r„r Pueue Roust FN.nFpommrNTALL tn.1tion as soon as It Is zvallahle and at the Same 6me <br /> It Ls provided to me or my representaHve. <br /> -type ofSarvice Requested: Furnish neCessan material &0,bor to install audible/visual overfill alarm on existing Veeder- <br /> Roots stem a er LG150-1. <br /> C4mmen6: 1% L <br /> 4 TV <br /> Inspectors Signature: <br /> Contractors Signature: SIX ��� <br /> �� pN <br /> Approved try: 5rployee#: Date: <br /> r <br /> F5519ned to: z.L` Fmplpyee�t: o Date: <br /> Date Service Completed(If already completed): Service Code: C7 p/E. <br /> Fee Amount Paid: Ip). CTC Payment Date: (b d <br /> J C_ <br /> Payment Type Invoice# Check Y Recelved By: - y <br /> :4 county 1 san Joaquin\env 1 forms 1 permlm rr palml <br /> 188-d zoo d W-1 EGE9 ZVE 84Z SOIEB 01 'ASIn9 DWrd H'8111-Woad 9480 EO-OI-qed <br />