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GtcVICE REQUEST <br />!L <br />�:II <br />Type of Business or Property <br />Store <br />Facility ID# <br />#19976 <br />Service Reques <br />� <br />Retail Gasoline - C <br />p <br />�1b <br />Owner / Operator 7 -Eleven Inc. Billing Party ❑ <br />Facility name: 7 -Eleven #19976 rEr_.I;,. ; FRICE;> <br />site address 1399 <br />North Main Street <br />Manteca <br />95336 <br />Street Number <br />direction <br />street name <br />city <br />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. <br />APN# <br />Land Use Application # <br />Phone #2 Ext. <br />I <br />BOS District <br />� <br />Location Codes <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor: Linda Steiger Billing Party ■ <br />Business Name <br />Sacramento Equipment Maintenance Company, Inc. (Wo #122462) <br />Phone # <br />( 916 ) 925-2716 <br />Mailing Address <br />2533 Connie Drive <br />Sacramento, CA 95815 <br />Fax # <br />(916)925-2816 <br />i l�Vr` <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 re"thisapplic�ationan at the work to be p rmed will be done in accordance with all SAN JOAQUIN CouNn Ordinance Codes, Standards, sTATE and FEDERAL <br />laws. <br />Applicant Signature: Date: �® <br />Property / Business Owner ❑ Operator / Manager Other Authorized Agent ■ President of Sacramento Equipment Maintenance Company, Inc. <br />If Applicant is not the Billing 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 <br />it is provided to me or my representative. <br />Tyne of Service Requested: <br />Cold start Veeder-Root TLS -350 console and reprogram to same specification, to clear module irregularities <br />Comments: <br />i l�Vr` <br />MAY 2 2�L <br />JJ <br />SAN <br />ROUlf/COUNTY <br />HEALTH,DEP <br />.-,..- <br />Approved by: <br />Employee#: <br />Date: <br />Assigned to: <br />Employee#: <br />Date: <br />Date Service Completed (if already completed): Service Code: <br />P / E: <br />e Amunt: <br />PPaymerot <br />Amount Paid: Ol 0 9 QU <br />Payment Date: <br />Type <br />l/ <br />Invoice # <br />Check # D <br />Received By: <br />v:\ county \ san joaquin \ env \ forms \ permits \ repairsl <br />