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SAN JOA COUNTY ENVIRONMENTAL HEAL EPARTMENT <br />SERVICE REQUEST ` <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />Jones Covey Group, Inc. <br />SERVICE REQUEST # <br />Pilot Travel Center <br />ExT' <br />975-4257 <br />�?�(; ( ,, <br />_L.i)r% �� <br />OWNER/ OPERATOR <br />CITY Rancho Cucamonga <br />STATE CA <br />Pilot Travel Centers LLC <br />EMPLOYEE #: <br />CHECK If BILLING ADDRESS® <br />FACILITY NAME Pilot Travel Centers LLC <br />SERVICE CODE:PIE: <br />1501DREss <br />N. <br />I <br />Jack Tone Rd. <br />Ripon <br />95366 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />PAY <br />614 <br />Rcei11 <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT <br />APN # <br />m J LAND USE APPLICATION # s; v '^A4Uf <br />(800) 562-6210 <br />j (j v <br />L FN�° ari <br />PHONE #2 EXT. <br />BOS DIS//TgqRICT <br />LOCATION CODE <br />CONTRACTOR SERVICE REQUESTOR <br />REQUESTOR <br />Robert Sills <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Jones Covey Group, Inc. <br />COMMENTS: U I w r: k: t a3 <br />Application for permit to Install new underground conduits and Veeder Root wiring <br />N NE# <br />x/14 <br />ExT' <br />975-4257 <br />HOME or MAILING ADDRESS <br />9595 Lucas Ranch Rd. #100 <br />EI FyEf I R 0N I"°^'I ,L`.'; r"!'"slmTl <br />FAX# <br />(909)484-0300 <br />CITY Rancho Cucamonga <br />STATE CA <br />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: �r��r� DATE: 9-22-2017 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Jones Covey Project Support <br />IfAPPmCANT 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 <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: Permit Application <br />COMMENTS: U I w r: k: t a3 <br />Application for permit to Install new underground conduits and Veeder Root wiring <br />SkP V�2d2017 <br />EI FyEf I R 0N I"°^'I ,L`.'; r"!'"slmTl <br />ACCEPTED BY: 5171 ®_ <br />T -'t �` <br />EMPLOYEE #: qCV/ <br />DAT ` ' '� f "'b � R S <br />L ot <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: t�i °T <br />•� c .% <br />Date Service Completed (if already Completed): <br />SERVICE CODE:PIE: <br />d ][ <br />!✓ <br />Fee Amount:(� 1' <br />Amount Paid r�-� �a vD <br />Payment Date -7 <br />Payment Type W- <br />Invoice # <br />Ch ck # J �%q3 <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />