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SERVICE REQUEST <br /> Type of Business or Property Facility ID# v Service Request# <br /> Retail Gasoline- C Store #32190 1 S O oo (-I l <br /> Owner/Operator 7-Eleven Inc. Billing Party ❑ <br /> Facility name: 7-Eleven #32190 <br /> site address 4943 South State Route 99 Stockton 95602 <br /> Street Number direction street name city zip code <br /> 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. APNI Land Use Application# <br /> Phone#2 Ext. 60S District Location Codes <br /> CONTRACTOR SERVICE RE UESTOR <br /> Requestor: Linda Steiger Billing Party <br /> Phone# <br /> Business Name <br /> Sacramento Equipment Maintenance Company,Inc. (Wo#117620) (916)925-2716 <br /> 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 DEPARTMENT 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 pre ed is a lication and that th to be performed will be done in accordance with all San Joaquin County Ordinance Codes,Standards,Stare and Federal <br /> laws. ICI I q�C�4 <br /> I Ni <br /> Applicant Signature: Date: <br /> Property/Business Owner 0 Operator/Manager 0 her Authorized Agent■ President of Sacramento Equipment Maintenance Company,Inc. <br /> If Applicant is net the Burro 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 it is <br /> provided to me or my representative. <br /> Type of Service Requested: Furnish necessary material&labor to repair/or retrofit existing OPW/Pomeco EVR spill bucket on(89)Mid-Grade fill. <br /> F CT <br /> Comments: RECEIVED <br /> NOV 12004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Approved by: 1)LEmployee#: Date: (( L(Loy <br /> Assigned to: !l tg 14T>= Employee#: 6 <br /> Date: C(, ( (7 <br /> Date Service Completed(if already completed): Service Code: I40 P/E: -(7B <br /> Fee Amount: 2`7 9-to Amount Paid: 0'1:7q. GT t[ I Payment Date: It it to`F <br /> Payment Type I Invoice# Check# n' -[�lP Received By: <br /> ZL <br /> v:\county\san joaquin\env\forms\permits\repairsl <br />