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• SERVICE REQUEST <br /> �. Type of Business or Property Facility 1D# ice Request# <br /> Retail Gasoline - C Store #32390" b� (J su Sery _DD it Ci-7 n <br /> Owner/Operator 7-Eleven Inc. Check if Billing Address❑ <br /> Facility name: 7-Eleven #32190 <br /> site address 4943 South State Route 99 Stockton 95602 <br /> Street Number direction street name <br /> city zip code <br /> Home or 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. APN# Land Use Application# <br /> Phone#2 Ext. BOS District Location Codes <br /> CONTRACTOR/SERVICE RE UESTOR <br /> Requestor: Linda Steiger Check if Billing Address■ <br /> Business Name Phone# <br /> Sacramento Equipment Maintenance Company,Inc. (Wo#121718) (916)925-2716 <br /> Home or 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 preps applicationALd that the work to be performed will be done in accordance with all San Joaquin County Ordinance Codes,Standards,Sate and Federal <br /> laws. <br /> Applicant Signature: Date: S� I )-7/U(1 <br /> Property/Business Owner ❑ Operator/Manager ❑ Other Authorized Agent■ President of Sacramento Equipment Maintenance Company,Inc. <br /> If Applicant is not the Bill!"Part,proof of authodzaUm 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(87)Chevron <br /> Regular&(91)Chevron Supreme fills. <br /> Comments: RECEIVED <br /> MAR 0 1 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Approved by: Employee#: 3 Date: <br /> Assigned to: Employee#: Date: <br /> Date Service Completed(if already completed): Service Cade: p P/E O <br /> Fee Amount Amount Paid: 0 Payment Date: 3 ( D tp <br /> Payment Type I Invoice# Check# 13-727 Received By: <br /> EHD 48-02-025(Revised 11/17/2003) <br /> v:\county\san joaquin\env\forms\permits\repairsl <br />