Laserfiche WebLink
° SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH SRT Fit <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />T VICE UEST # <br />Gasoline Dispensing Facility <br />FA 000 3(Q I <br />SR00` p i�)3 <br />OWNER / OPERATOR <br />ENVIRORIh/II �n <br />Harshad Patel <br />K-���I��IN���UOR�� <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 />Citv <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />(National Petroleum) <br />398%reet Number <br />Balentive Ave. street Name <br />CITY <br />STATE ZIP <br />Newark <br />CA 94560 <br />PHONE #1 ExT. <br />qpN # <br />LAND USE APPLICATION # <br />( 510 ) 600-3360 <br />PHONE #z ExT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <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/BusfNLss OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZEDAGENTIJDispatch 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 JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. PA v. _ <br />TYPE OF SERVICE REQUESTED: Replace all dispensers and adapter C41, F/V°rl <br />PI A <br />COMMENTS: S4N <br />APR 17 2017HoF COV <br />Fa,�R q44-�Y <br />MFM <br />ENVIRONMENTAL HEALTH <br />ACCEPTED BY: E DATE: I <br />ASSIGNED TO: MC a <br />-Q EMPLOYEE #: DATE: O <br />Date Service Completed (if already completed): SERVICE CODE: P 1 <br />Fee Amount: '') Amount Paid-16tf/7UD Payment Date /7 <br />Payment Type invoice # Che # (�)l2 , '*0.7 C Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />