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+ SAN JOAQUOUNTY ENVIRONMENTAL HEALEPARTMENT <br /> OSERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fueling Station �� SOD 701o7$ <br /> OWNER/OPERATOR pilot Flying J LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Pilot Flying J <br /> SITE ADDRESS 1501 N Jack Tone Road Ripon 95366 <br /> Street Number Direction Street Name city Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Jones Covey Group, Inc. CHECK if BILLINGADDRESSE] <br /> BUSINESS NAME Jones Covey Group, Inc. PHONE# E"T. <br /> 888 972-7581 <br /> HOME or MAILING ADDRESS 9595 Lucas Ranch Road #100 FAx# <br /> (909 ) 484-0300 <br /> CITE' 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 F DERAL la s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT[M Permits <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: 9 ` <br /> ASSIGNED TO: d EMPLOYEE#: DATE: ?/3 Oki <br /> Date Service Completed (if already completed): SERVICE CODE: 17g P/E: .2306' <br /> Fee Amount: �i 10 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />