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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID�7# SERVICE REQUEST# GASOLINE DISPENSING FACILITY --A 66 7qi a3 OWNER/OPERATOR c/ CHECK If BILLING ADDRESS BALAJI ANGLE FACILITY NAME ANGLE PETROLEUM SITE ADDRESS MORELAND STREET STOCKTON 5 7700 Street Number Direction Street Name City �ae� HOME or MAILING ADDRESS (If Different from Site Address) A V� Street Number Street Name �l CITY STATE Zlp q/y JOgQ PHONE#1 EXT. APN# h LAND USE APPLICATION# 4T Op q PHONE#2 EXT. JFBOS DISTRICT LOCATION CODE ( ) ()O a— Cl-l CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS ERIC SANTOS BUSINESS NAME PHONE# EXT. CONFIDENCE UST SERVICES, INC. 323 485-1015 HOME or MAILING ADDRESS FAX# 16250 MEACHAM ROAD ( ) CITY STATE ZIP BAKERSFIELD CA 93314 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/Or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: /�/, DATE: 5/15/18 PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT Q OFFICE CLERK It APPLICANT IS not the BILLING PARTY. proof of authorization to Sign IS required Title 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 results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or my representative. TYPE OF SERVICE REQUESTED:MODIFICATION OF UDC. COMMENTS: REPLACEMENT OF UDC#5/6. REMOVE(1)DISPENSER#5/6,SET ASIDE.CUT CONCRETE AROUND UDC#5/6 TO REPLACE WITH NEW BRAVO DOUBLE WALL UDC. EXPOSE PIPING(PRODUCT,VAPOR,AND ELECTRICAL).BLOW ALL FUEL BACK INTO TANK BEFORE CUTTING LINES BACK FROM OLD UDC.REMOVE OLD UDC. PULL UP TO(3)SOIL SAMPLES FOR TESTING.INSTALL NEW UDC WITH ALL NEW PIPING PENETRATIONS(PRODUCT,VAPOR,AND ELECTRICAL).BACKFILL AND POUR NEW CONCRETE AROUND NEW UDC.REINSTALL DISPENSER. ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: r, , EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE PIE: Fee Amount: LAC:J�' Amount Paid �qr"LI& w Payment Date Payment Type Invoice# Check# 111 —;9 Received By: G EHD 48-02-025 SR FORM(Golden Rod) 07/17/08