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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property F, CILITY10 #11 , SERVICE REQUEST # <br /> Flying J Travel Center #618 Flp <br /> OWNER / OPERATOR O O CHECK if BILLINGADDRESSO <br /> DECPilot Travel Centers LLC 0 2019 <br /> FACILITY NAME Flying J Travel Center 4618 <br /> 1501DREss F= 41141PISINMEN IAL N . Jack Tone Rd . � � /� 'r- EA TI on 95366 <br /> ogg� gStreet Number Direction Susie F. AR CI ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name /`A' it <br /> CITY STATE ZIP p •� <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # �® <br /> 1800 ) 562-6210d / if <br /> Fry <br /> PHONE #2 EXT• BOS DISTRICT Locki �"�Y(/ 2O�d <br /> ( ) N BIRO <br /> IOU/At C UIQ <br /> CONTRACTOR / SERVICE REQUESTOR FpJ <br /> r�EQUESTOR <br /> Andrew Garcia CHECK If BILLING ADDRESS <br /> BUSINESS NAME Jones Covey Group , Inc . PTA ) <br /> A 975 - 4257 Ext <br /> HOME or MAILING ADDRESS FAx # <br /> 9595 Lucas Ranch Rd . # 100 ( 909 ) 484- 0300 <br /> CITY Rancho Cucamonga STATE CA ZIP 91730 <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 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 ❑ OTHER AUTHORIZED AGENT ® Jones Covey Project Suppori✓ <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 assess �rl <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available aat,;he, sa e tune I# �is <br /> provided to me or my representative. �y <br /> TYPE OF SERVICE REQUESTED : Permit Application J <br /> COMMENTS: To perform SB989 Repairs on UDC 13 & UDC 24 Sat . <br /> n BMW T <br /> ACCEPTED BY: � ��- EMPLOYEE # : DATE: <br /> ASSIGNED TO: EMPLOYEE # : DATE: //A! <br /> �v <br /> Date Service Completed (if already complete : e= _ SERVICE CODE: I P I E:��p� <br /> Fee Amount : 4' 2 t% T Amount Paid �� Payment Date <br /> Payment Type JCI�Pl Invoice # Check # 103 7 Received By: <br /> EHD 48.02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />