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SERVICE REQUEST <br /> Ty¢e of Baslness or Property FACILITY ID: SERVICE REQUEST# <br /> ,i <br /> GAS STATION <br /> 0 NERI OPERATOR 841RI41 PASM 0 <br /> SAFEWAY,, INC. <br /> FNF`UTyFEWAY FUEL CENTER #1769 <br /> SEADORESS <br /> 2808 - ;,N,,,,� awes. COUNTRY CLUB <br /> swa <br /> Mililing Address IIf Different from Site Address) <br /> 5918 STONERIDGE MALL ROAD <br /> Cm• STATE Zv <br /> 1 PLEASANTON CA 94558 <br /> PHONE 91 W. APN# LANDUSEAPPLICATION# <br /> 25 467-3000 121-181-020 <br /> PNONE tf2 ' ar. BOS Du-rRlcr LOtafloNCOOE - <br /> I <br /> CONTRACTOR I SERVICE REOUESTOR <br /> RiJIUESTOR 5D.Lm P <br /> 5dSINESS NAMEPNONE# esr. <br /> Eya��A �— 54fi-yy <br /> MXu GADDRESS <br /> crfr STATECA ZIP <br /> 81 INACKNOWLEDGEMENT, 1.Ne undersigned property or business owner.operator or aulhoroad agent of same,acknowledge that ad ske ad"project SDecfc <br /> Pti uC HEAITN SERVYFS EaVRONLENTAL HEALTM OrnsioN hourly charges assocated vim IM pro)ector ac"wW be blled m me or my business 31 idenvied on this form <br /> 1 ago mRty;that Ine pared N� Dliwtion and wrk m be padamxd wm be done in aaardanae++m all SAN JOAWw COURry Ordine�s Codas,Sfar+daNs,SPATE and <br /> FEPERAL Iaws. <br /> 0' OATS 2/21/01 <br /> P,PfP <br /> ERN/jeus4nE55 0 PEfrATOA)MANAGm ❑ O WAV ,,OKL DAGENT lg ,TEFF T,EE — ._T)_A_ <br /> ij aAwwcwrarnrQ•Bruc P,row.p'eddarnlstodan malpwS nwAuwl Sithe <br /> AUTHORIZATION TO R EASE INFORMATION:When appaobie.L the awneror operamrat me property located at me auoN sde address.heneby auNmool the release of <br /> aqj and all results.geoledmiral date angor emrvonm2nDUskO assessment inkemadon to an SM JOAaIw Cww Pusuc NFAynr SERvims EwRouwxua KF . DMVOR as amn <br /> aija is available and at Ne same dme a is prvwided to ma or my represmadve. <br /> T*E OF SERVICE REQUESTED: <br /> CQYYExTS,: � - <br /> 1 PAYMENT <br /> j� RECEIVED <br /> FEB 2 2 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> INSPECIORIS SIGNATURE: CONTRACTOR'S SIGNATURE: NVIRONMENTAL HEALTH DIVISION <br /> ,PROVEOi ; EYPLDTE_T. D k DATE: <br /> ASSIGNW;,Q: EautoTEE#. DATE: <br /> iC)W <br /> Date Service Completed{rt already completed): SExAMCODe T-3D-3 <br /> F9e Amount Amount Paid Payment Date <br /> Payment Type Invoice# Check It Received By: <br /> li <br /> I <br /> i <br /> I <br /> TOTAL P.11 <br />