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SAN JOAQUPCOUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> n <br /> Flying J Travel Center#618 <br /> OWNER/OPERATOR <br /> Pilot Travel Centers LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Flying J Travel Center#618 <br /> SITE ADDRESS N. Jack Tone Rd. Ripon 95366 <br /> 1501 <br /> Street Number Direction Street Name Ci Zi 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 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Robert Sills CHECK if BILLING ADDRESSO <br /> BUSINESS NAMEExr. <br /> Jones Covey Group, Inc. PHN 975-4257 <br /> HOME or MAILING ADDRESS FAx# <br /> 9595 Lucas Ranch Rd. #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 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 4 - " DATE: 5-9-2018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Jones Covey Project Support <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 th&Wne time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Permit Application <br /> COMMENTS: To resolve NOV for repairs made and provide documentation for review. % I� <br /> HM.�Ro vVN ?oj8 <br /> FNT <br /> ACCEPTED BY: D i i� ((�/t n LcEMPLOYEE#: 0,w DATE: 5-q <br /> ASSIGNED TO: CMw EMPLOYEE#: DATE: r^ ^t -•l�x�C <br /> Date Service Completed (if already completed): SERVICE CODE: C f� I PIE: <br /> Fee Amount: vl i� Amount Paid 0b Payment Date <br /> Payment Type Invoice# Check# E57 7F.�7 Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />