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SERVICE REQUEST (Tank VZI) (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # L% 5 V 9 C7 1 INVOICE # <br /> FACILITY NAMESOu�hlancl 7`��e�en0�2#2Olo3Z BILLING PARTY Y- / <br /> �J <br /> SITE ADDRESS 4&?-7 oay no Chive, <br /> CITY CA ZIP 85207 <br /> NER/OPERATOR �olsl h land Car parai'�on BILLING PARTY / N <br /> DBA 7-eleven. yre 'ZO&!2 Z> PHONE #1 (- 1 l(P ) S67- 67,6,91 <br /> ADDRESS Z33 1 L�LJYJ� t��ad �a�/ 101 PHONE #2 ((1 1 CO :&5] -7711 <br /> CITY ( Old Ter STATE GA ZIP 95&70 <br /> APN # - and Use ca <br /> Ld UApplication # <br /> BOS Dist Location Code <br /> 1';RAG4GR smd�er IF <br /> - 1 :1 <br /> RVICE REQUESTOR R f1L �eSlgYl (!JtOJ� 1:z�ad (i2nino) BILLING PARTY Y / N <br /> DBA Ael2vnl T(Jr PHONE #1 (°Illy )A&- 400'�) <br /> ILING ADDRESS (O5d Howe Avenue � 0+ FAX # ( '1167 )(A& - 4&71 <br /> CITY Sacs rnen+D STATE GQ zIP 50Z-5 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> QU1N COUNTY Ordinance Codes and Standards, State and Federal laws. ' <br /> PPLICANT'S SIGNATURE .��i-���' APR 2 9 MR <br /> Title: ./SGig4 for _)QL hl' (.2I""�i00 Date: 4/17Af5 SANJO. QOIN*COUNT+ <br /> NVIPC7NNiENTAl_HEALTH F*:`V3SIdlv <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> ,it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: Service Code 3 <br /> Assigned to �O'kf4 �� (.�--'�Erptoyee # { Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT o Tr <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> x '102, - �+(a� 1� 8 sa3s Ci5 <br /> SUP V / / ACCT _/ / UNIT CLK _/ / <br />