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` SAN JOA 11 OUNTY ENVIRONMENTAL HE r <br />SERVICE REQUEST I VE D <br />Type of Business or Property <br />FACILITY ID #F"0711", <br />I ER QUEST # <br />A 4�0 <br />Gasoline Dispensing Facility <br />F� 0 0 0 3 1 <br />-� 3 <br />OWNER / OPERATOR <br />ENVIROKKWI� <br />AL�UCI <br />Harshad Patel <br />If�BI <br />FACILITY NAME <br />ARP Mini Mart <br />631-3870 <br />SITE ADDRESS <br />FAX # <br />16250 Meacham Road <br />25775 <br />587-9758 <br />Patterson Pass Road <br />Tracy <br />95377 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zin Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />(National Petroleum) <br />3989%reet Number <br />Balentive Ave. street Name <br />CITY <br />STATE ZIP <br />Newark <br />CA 94560 <br />PH0NE#1 EXT <br />APN # <br />LAND USE APPLICATION # <br />( 510 ) 600-3360 <br />PHONE#2 EXT. <br />( ) <br />It <br />BOS DISTRICT <br />7� <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Karli Karns <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# <br />EXT. <br />Confidence UST Services, Inc. <br />( 661 ) <br />631-3870 <br />HOME or MAILING ADDRESS <br />FAX # <br />16250 Meacham Road <br />( 661 ) <br />587-9758 <br />CITY Bakersfield <br />STATE CA <br />zip 93314 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this app)ication and that the work be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 04/14/2017 <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER OTHER AUTHORIZED AGENT W1 Dispatch Coord., Confidence UST <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. A,q <br />TYPE OF SERVICE REQUESTED: Replace all dispensers and adapter Cly/V T <br />COMMENTS: <br />APR 17 2017 'toe0y <br />MFM_ <br />_ ENVIRONMENTAL HEALTH <br />ACCEPTED BY: ERT MENT DATE: I (� <br />ASSIGNED TO: �� �n� EMPLOYEE #: DATE: 04 14 1 <br />Date Service Completed (if alre'a'dy completed): SERVICE CODE:19e P I : 23 <br />Fee Amount: ` �� Amount Pai 7Payment Date �/7 l <br />Payment Type Tl Invoice # Che # �ndz�c�7C Received By: <br />zs. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />