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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 <br /> Flying J Travel Center#618 � <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Pilot Travel Centers LLC <br /> FAcIuTrNAME Flying J Travel Center#618 <br /> S�TgAD�DRESS N.=Jack Tone Rd. Ripon 95366 <br /> Street Number DirectioStreet Name city Zia 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 /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Robert Sills CHECK if BILLINGADDRESS13 <br /> BUSINESS NAMEP ExT <br /> Jones Covey Group, Inc. 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 /> j 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: ( DATE: 5-9-2018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Jones Covey Project Support <br /> 1fAPPL1CANT 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 t�In_a time it is <br /> provided to me or my representative. "Ir <br /> TYPE OF SERVICE REQUESTED: Permit Application A <br /> COMMENTS: AD <br /> To resolve NOV for repairs made and provide documentation for review. <br /> 0 ZQ <br /> E4C Ro ty 18 <br /> of"M��Hry <br /> ACCEPTED BY: )Gt'.VVc EMPLOYEE#: Otw DATE: i�i-Q <br /> ASSIGNED TO: 'w l EMPLOYEE#: ctw <br /> DATE: 6 -61-j-0(,�j <br /> Date Service Completed (if already completed): SERVICE CODE: C C/tT PIE: a&)6 <br /> Fee Amount: 41 <br /> q i Amount Paid 9/�ODPayment Date <br /> Payment Type Invoice# Check# $S-�7ga-� Rece ed By:Y,� i <br /> EHD 4B-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> i <br /> i <br /> i <br />