Laserfiche WebLink
SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTHIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Flying J Travel Center#618 47A00o'(D(g72J k U UJ c,1 Ib 3 <br /> OWNER/OPERATOR <br /> Pilot Travel Centers LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Flying J Travel Center#618 <br /> SITE ADDRESS 1501 N. I Jack Tone Rd Ripon 95366 <br /> Street Number Direction Street Name City Zip 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 /> (800) 562-6210 �� ' 1 V' L3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) Gg54 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Issac Garcia <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Jones Covey Group Inc PHONE# EXT. <br /> 888 972-7581 <br /> HOME or MAILING ADDRESS FAX# <br /> 9595 Lucas Ranch Rd Suite 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: c- DATE: 05/29/2018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® Jones Covey Project Manager <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provjded to me or <br /> my representative. ��77 <br /> TYPE OF SERVICE REQUESTED: Permit Application C <br /> COMMENTS: 4 <br /> To resolve NOV and provide documentation for review 30 <br /> �"�O 2018 <br /> H FN�jgQU�,y <br /> �GTy��NpACO4gr�Y <br /> FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: o EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: ; 9 <br /> Fee Amount: Amount Paid 7s�j U� Payment Date 5 <br /> Payment Type Invoice# Ch k# /4�3?g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />