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RECOUNTY ENVIRONMENTAL HEALTH REPARTMENT <br />DEC 0 7 2016 SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Inc. <br />SERVICE REQUEST # <br />' — <br />11 <br />PHONE# EXT. <br />�(T <br />OWNER / OPEWkIiO <br />( 909 730-9185 <br />HOME or MAILING ADDRESS 9595 Lucas Ranch Road #1100 <br />Pilot Travel Centers, LLC <br />FAX# <br />CHECKifBILUNGADDRESS[]— <br />DDRESS[]FACILITYNAME <br />FACILITY NAME <br />Pilot Travel Centers, LLC <br />( 909) 484-0300 <br />CITY Rancho Cucamonga <br />SITE ADDRESS <br />1501 <br />Recei ed By: <br />Jack Tone Road <br />Ripon <br />p <br />95366 <br />Street Number <br />Dilrection <br />Street Name <br />Ci <br />ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />5508 <br />Lonas Raod <br />Street Number <br />reet Name <br />CrrY <br />Knoxville <br />STATE TN ZIP 37909 PAY <br />PHONE #1 EXT <br />APN # <br />LAND <br />USE APPLICATION # RECEIV <br />(800 )562-6210 <br />PHONE #2 EXr• <br />( 209 ) 599-4141 <br />BOS DISTRICT <br />II <br />LOCATION C DE t <br />SAID JOgQU�N <br />E COIJ <br />CONTRACTOR / SERVICE REinuF.CTnR <br />116 <br />IkAO'H oEPTTA��a <br />REQt1ESTOR <br />Jones Covey Group, <br />COMMENTS: T-5 Premium Unleaded STP Sump - Remove and replace three (3) non -fiberglass penetrations with Bravo SWAT <br />Inc. <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Jones Covey Group, Inc. <br />ACCEPTED BY: <br />PHONE# EXT. <br />DATE: <br />( 909 730-9185 <br />HOME or MAILING ADDRESS 9595 Lucas Ranch Road #1100 <br />ASSIGNED TO: CEMPLOYEE#: <br />FAX# <br />DATE: 16 <br />Date Service Completed (if alrea y completed): LL SERVICE CODE: (� D PIE: 230 p <br />( 909) 484-0300 <br />CITY Rancho Cucamonga <br />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 a%FED laws. <br />F . <br />APPLICANT'S SIGNATURE: DATE: 12-7-16 <br />J <br />PROPERTu / BuswESS NATURE: <br />OP 1i MANAGER ❑ OTHERAUTAORIZED AGmYT ® Contractor <br />Ife1PPLicANT is not the BiLL[NGPARTY. 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 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: Penetration Repairs <br />COMMENTS: T-5 Premium Unleaded STP Sump - Remove and replace three (3) non -fiberglass penetrations with Bravo SWAT <br />3/4" repair penetrations. <br />T-6 Auto Diesel STP Sump - Remove and replace one (1) non -fiberglass penetration with Bravo SWAT 3/4" <br />repair penetration. <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />/ <br />ASSIGNED TO: CEMPLOYEE#: <br />DATE: 16 <br />Date Service Completed (if alrea y completed): LL SERVICE CODE: (� D PIE: 230 p <br />Fee Amount: (,��"� Amount Paid �I-I Payment Date <br />Payment Type Invoice # <br />Ch # <br />Recei ed By: <br />it 611 L <br />48-02-02 <br />EHD <br />REVISED 11117/2003 <br />SR FORM (Golden Rod) <br />