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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Transportation Fueling Site FA0003854 OWNER / OPERATOR CHECK if BILLING ADDRES Ruben B erle S FACILITY NAME SITE ADDRESS 1535 E Pescadero Avenue Tracy 95304 Street Number Direction Street Name city ZI Code HOME or MAILING ADDRESS (if Different from Site Address) 10990 Roe Avenue , MS A650 , Attn : Env . Serv . Street Number Street Name CITY Overland Park STATE zip PHONE #1 EXT. APN # LAND USE APPLICATION # (913) 344-3000 PHONE #2 EXT• BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Janelle Dockham CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT. Confidence UST Services HOME or MAILING ADDRESS FAX # 16250 Meacham Road ( 661 587-9758 CITY Bakersfield STATE ZIP 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 . I 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 : CPDATE : March 11 , 2020 04 PROPERTY / BUSINESS OWNER OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT CI Manager - Fnv . SP. rv _ If 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 to 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: RemOVe existin 4"x96 " tank riser & replace with shorter: install CNI 214P COMMENTS: Remove existing 4"x96" tank riser & replace with shorter riser . Install CNI 214P spill container on new riser. ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO : EMPLOYEE #: DATE: Date Service Completed (if already completed) : SERVICE CODE: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By : f 1 EHD 48-02-025 SR FORM ) 07/17/08 (Golden Rod