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S., <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITI ID# SERVICE REQUEST# <br /> Gas Station/Truck Stop O®06?- Z S/2,90(P q(..'0/0 = <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS[:] <br /> Pilot Travel Centers <br /> FACILITY NAME Pilot Flying J #618 <br /> SITE ADDRESS Xt,.:T Jack TonesiR <br /> 2 I - Ripon 95326 <br /> 1501 streotNumberl D C& Zip Code <br /> HOMEor MAILING ADDRESS (if Different from Site Address) <br /> Street Number gtreat Name <br /> CITY STATE Zip <br /> PHONE#1 ExT. APN# LAND Use APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE IM,QUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Glenn Owens <br /> BUSINESS NAME PHONE# ExT. <br /> Jones Covey Group, Inc. B88 972-7581 <br /> HOME or MAILING ADDRESS FAX# <br /> 9595 Lucas Ranch Rd. Ste 100 (909) 484-0300 <br /> CITY Rancho Cucamonga STATE CA ZIP 91730 <br /> BILLING ACKNOWLE12GEMENT: 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 or <br /> activity will be billed to me or my business as Identified on this form. <br /> A also certify that I have prepared this application and that the work to be performed will be done in accordance with 811 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12/9/13 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT In contractor/Construction Mgr <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 above <br /> site address,hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at therovided to me or <br /> my representative. MVIX/M <br /> TYPE or SERVICE REQUESTED: <br /> COMMENTS: JUN 16 2014 <br /> f (l <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 9:Va <br /> Fee Amount: Amount Paidi�­ Payment Date <br /> Payment Type / I 'Z ' F <br /> Invoice# Check# ed By: <br /> EHD 48-02-025SIR FORM(Golden Rod) <br /> L <br />