COMPLIANCE INFO 2016 - 2017 - Laserfiche WebLink

Home Browse Search

SAN JOAQL)IN COUNTY ENVIRONMENTAL HEAL, A DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gasoline Dispensing Facility ,� !,A�6 IA. �V J ��? �� 7-� , i I �(� cJ`-' OWNER /OPERATOR " - ' ,� � L PHONE# Harshad Patel Confidence UST Services, Inc. CHECK if BILLING ADDRESS FACILITY NAME ! -: I TH HOME or MAILING ADDRESS ARP Mini Mart FAX # ENVIRONMENTAL SITE ADDRESS ( 661 ) 587-9758 CITY Bakersfield STATE CA ZIP 93314 25775 ASSIGNED TO: Patterson Pass Road Tracy 95377 Street Number Direction Date Service Completed (if already Completed: Street Name SERVICE CODE: 7 city Zin Code HOME or MAILING ADDRESS (If Different from Site Address) 1 Amount Paid q 1 (National Petroleum) 398991reet Number Balentive Ave. Street Name CITY STATE ZIP Newark CA 94560 PHONE #1 EXT. APN # LAND U APPLICATION At (510 ) 600-3360 PHONE #2 EXT•OS ( )100 DISTRICT 7 LOCATION CODE CONTRACTOASERVIdEXEQUESTOR l RER Replace dispensers and UDC's 3/4 & 7/8. Convert 87 Siphon tank to Diesel. Inst W-1-4 isp's. COMMENTS: Karli Karns Karns �r�� CHECK if BILLING ADDRESSIZ BUSINESS NAME PHONE# EXT. Confidence UST Services, Inc. 661 631-3870 HOME or MAILING ADDRESS FAX # ENVIRONMENTAL 16250 Meacham Road ( 661 ) 587-9758 CITY Bakersfield STATE CA ZIP 93314 BILLING ACKNOWLEDGEI EN . I, the �d tgned property or business owner, operator or authorized agent of same, acknowledge that all site and/or ect specific VIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me m usiness identified on this form. I also certify that I ve pre a is a li ion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinan Cod Stan r and FEDERA 1 ws. APPLICANT'S SI TUR DATE: 05/05/2017 PROPERTY/ BUSINESS OWN OPERATOR/ MANAGER OTHER AUTHORIZED AGENT Dispatch Coord., ConfidencE' UST IfAPPLICA i of the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO LEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, h Ay authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SyfJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or representative. r r St i P' ti� la '1"") ` TYPE OF SERVIC Replace dispensers and UDC's 3/4 & 7/8. Convert 87 Siphon tank to Diesel. Inst W-1-4 isp's. COMMENTS: t�EQUESTED: ✓T �jt(JCI I Qer 1=� ��k� 0f r �r�� RECEIVED Ma's 10 2017 SAN JOAQUIN COUNTY ENVIRONMENTAL Fi ACCEPTED BY:AgrA muv- q—`v� EMPLOYEE #: DATE: ASSIGNED TO: V"'t w" MLLr ne EMPLOYEE #: DATE: Date Service Completed (if already Completed: SERVICE CODE: 7 PIE: Fee Amount: 4 �-11 7 00 1 Amount Paid q 1 Payment Date ")ayment Type / Invoice # -etteuk #e'riq�A RISS L 6, Received By: 8-02-025 IL ED 11/17/2003 S/5� 17 SR FORM (Golden Rod)