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SAN JOAQUr&UNTY ENVIRONMENTAL HEALTH OARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Station/Truck Stop 4p�-7� 5",0 & I- i� Z 7 - OWNER I OPERATOR (888 ) 972-7581 205 CHECK if BILLING ADDRESSE] Pilot Travel Centers LLC FAX # 9595 Lucas anch Road #100 FACILITY NAME (909 ) 484-0300 CITY Rancho Cucamonga Pilot -Flying J #618 f -14N, f tiep'l-l" 0 -Ppst ACCEPTED BY: SITE ADDRESS I Jack Tone Road ASSIGNED TO: Ripon 95366 1501 Date Service Completed (if already completed): I SERVICE CODE 90c, rP I E�,136,f Fee Amount: 001 /-&w Street Number IN, D rection nt Date Street Name Payment Type City Zip Code HOME or MAILING ADDRESS (if Different from Site Address) Received By: Street Number Street Name CITY STATE Zip PHONE#1 ExT. APN # LAND USE APPLICATION PHONE#2 ExT. BOS DISTRICT ATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Holly Mendez CHECK if BILLING ADDRESS BUSINESS NAME COMMENTS: PHONE# EXT. Jones Covey Group, Inc. (888 ) 972-7581 205 HOME or MAILING ADDRESS FAX # 9595 Lucas anch Road #100 (909 ) 484-0300 CITY Rancho Cucamonga CA STATE 91730 Zip BILLING ACKNOWLEDGEMENT: 1, 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: C4't'�-p PROPERTY/ BusINESS OWNERO OPERATOR/ MANAGER DATE: 5/26/2011 OTHER AUTHORIZED AGENT 91 Contractor I EnAronmental Compliance 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. .-W. TYPE OF SERVICE REQUESTED: P I COMMENTS: r CO"o'" OP,Ck%3lt4 f -14N, f tiep'l-l" 0 -Ppst ACCEPTED BY: EMPLOYEE M qess DATE: ASSIGNED TO: EMPLOYEE M 'Z/0 ;A0 DATE: Date Service Completed (if already completed): I SERVICE CODE 90c, rP I E�,136,f Fee Amount: 001 /-&w Amount Paid nt Date Payment Type invoice# heck # Received By: EHD 48-02-025 SIR FORM (Golden Rod) REVISED 11/1712003