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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ` FACILITY ID# SERVICE REQUEST# <br /> Flying J Travel Center#618 -l>C�C '� ' <br /> OWNER/OPERATOR ✓ <br /> CHECK if BILLING ADDRESS O <br /> Pilot Travel Centers LLC O1!; <br /> FACILmNAME Flying J Travel Center 4618 <br /> SIT1501DREss N. Jack Tone Rd.: , y—��� I AL fir' IRipon 7 <br /> 95366 <br /> Street Number I Orectic Streot - city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / <br /> Slrool Number Slreal Name p� <br /> CITY STATE ZIP •��� <br /> PHONE#1 ExT• APN# LAND USE APPLICATION <br /> (800 ) 562-6210 <br /> PHONE#T ExT• BOS DISTRICT LOG/1 <br /> ( ) N lRO. C V <br /> N <br /> �Y <br /> CONTRACTOR/SERVICE REQUESTOR �p�IT F, <br /> REQUESTOR Andrew Garcia CHECK If BILLING ADDRESS <br /> BUSINESS NAME Jones Covey Group, Inc. PH4/N 975-4257 En. <br /> HOME or MAILING ADDRESS FAx# <br /> 9595 Lucas Ranch Rd. #100 (909)484-0300 <br /> CITY Rancho Cucamonga STATE CA Z'P 91730 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and DERAL laws. r <br /> APPLICANT'S SIGNATURE: DATE: 12-26-2019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER IJ OTHER AUTHORIZED ACENT[M Jones Covey Project Suppoll.11 <br /> If APPLICANT is not the R/ xyg P4R7Y.proofof authorization to sign is required Title A <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operiater offlhe property loc t� il�eabovesite address, hereby authorize the release of any and all results, geotechnical data atrd/4r, environmental/sts• , es t information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it isavailable atI I/S t lime� ~�. <br /> provided to me or my representative. ry <br /> TYPE OF SERVICE REQUESTED:-Perms ica iQO— J, <br /> COMMENTS: To perform SB989 Repairs on UDC 13 & UDC 24 Sat. <br /> MIgl�� <br /> I-) PW u4l <br /> ACCEPTED BY: � ��� EMPLOYEE#: DATE: <br /> ASSIGNED TO: / , �/ EMPLOYEE M DATE: /5 �c <br /> Date Service Completed (If already compieto : SERVICE CODE: r �� J PIE:•� �% <br /> Fee Amount: 1"520T Amount Paid UD Payment Date <br /> Payment Type Invoice# Check# 1o3G 7SZ� Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />