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Gi—CL—LGG1 1G•GChe'I �KUI'I I iov.l.l`•vcv.i� ... <br /> ; <br /> v� SERVICE REQUEST rt/ <br /> Type of El6siness or Property FACILTfY fD: SERVICE REQUEST Y <br /> GAS STATION <br /> 1 <br /> OWNER I OPERATOR SUM PARTY 0 <br /> ,SAFEWAY,, INC. <br /> F SAFEWAY FUEL CENTER #1769 <br /> Sf�E AD0R 2 <br /> 2808 9ti,,n ,.,, p„q„ COUNTRY CLUB svvay.n. BT,�. T„A„ <br /> Mailing Address (If Different from Site Address) <br /> 5918 STONERIDGE MALL ROAD <br /> City STATE Zp <br /> PLEASANTON CA 94558 <br /> PHONE tit , L" APNq LAND USEAPPLCAnomX <br /> i92J5 467-3000 121-181-020 <br /> PHONE 92 - Or. DOS DISTRICT - LOUTa)NCODE" <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RFJ7UESTOR BalaH'PARTY 0 <br /> T.B.D <br /> BUSINESS NAyE PNONE1t ea. <br /> MAUUM AWRPda FARC <br /> Ci4y STATE ZIP <br /> BILIING ACKNOWLEDGEM NT:I.ever undersigned pimp"or business owner.operator or aurhorkad agent of sama ar}nowlaoe Met ad s to ardor poje t spe&4 <br /> PtleLle HEALTH SF-WGES E,,n;EaaWAL MEALTH DmSoN hwdyawyes aS59®Td we chef plopaor a"wdl be blIIed to me or my business as idelle(I!0 Qt ft td m <br /> I it,mMy.Sat I Mve pteaaTed S' ppTloa,n and t-A Ile Wdt to be podomwd WR be done,in aWYdar of w'iet all SAN JdAW W COUNTY Ordinance Codec.Standards•STAFF and <br /> FEpERALIM. -� <br /> AS LLU" �" Tc��- �►1T DATE: 2/21/01 <br /> P"ERryligusereSt 0 TORIMANAGER OTHERAMORM AGENT nT .TEFF T.FF — R.D_A_ <br /> i <br /> dAPRLATTir AM MastwCPAmr peddMNsmeon palprbneuied TIAs <br /> AUTHORIZATION TO RELEASE INFORMAT70L1:Vmm apokable,L die owneror opsnsor A Se property located at Tie atlwe sire adifsea.hereby aurariM ale release of <br /> any and ere M oft,gmtedmlol data an gW aHvonmerTbusae aasnaunmt in(am idan In aw SAH JOAOU CgixTT PUat.'G MEALTN SERvrM$E`MHOMIaonALHEAL:N OMWM as soon <br /> asst is avviiiWo and M arc same Mm 4 is owided to me Or my rept®cRsave. <br /> T*OF SERVGE REQUESTED: - <br /> I <br /> CpssesFRiS: <br /> i <br /> I{ <br /> I{ <br /> it <br /> .i <br /> bea,GcToR's SIGNATURE: Comma cTotes SIGNATURE: <br /> A�PROVEDMT: EMPLOYEE#. DAT-: <br /> ASSGNE0 T0: Emmovim ik DATE: <br /> u <br /> Date Service Completed (d already completed): <br /> Fee Amount: <br /> Amount Paid Payment Date <br /> !tent Type Invoice 0 Check C Received By. <br /> i <br /> j <br /> 1� <br /> TOTAL P.11 <br />