Laserfiche WebLink
SAN JOAQUAOUNTY ENVIRONMENTAL HEALTH OARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />Gas Station/Truck Stop <br />0 (- <br />BUSINESS NAME <br />PHONE# <br />Jones CoveV Group, Inc. <br />OWNER / OPERATOR <br />972-7581 <br />HOME or MAILING ADDRESS <br />FAX # <br />CHECK If BILLING ADDRESS <br />Pilot Travel Centers <br />(909)484-0300 <br />FACILITY NAME <br />STATE CA <br />ZIP 91730 <br />Pilot Flying J #617 <br />DATE: <br />Date Service Completed (if already co leted): <br />SITE S ADDRES <br />N <br />Thornton Ma� <br />Fee Amount: ?7'� <br />\IRPayment <br />Lodi <br />95242 <br />treet Number <br />Direction <br />Type <br />reet ame <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #t EXT. <br />APN # <br />LAND USE APPLICATION # <br />( ) <br />C s _ i�iC) 1 1q - <br />PHONE #2 EXT. <br />BOS DISTRICT <br />1[C1. <br />LOCATION CODE <br />( ) <br />60u, <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />Glenn Owens <br />3 <br />� ?0 <br />BUSINESS NAME <br />PHONE# <br />EXT' <br />Jones CoveV Group, Inc. <br />888 <br />972-7581 <br />HOME or MAILING ADDRESS <br />FAX # <br />9595 Lucas Ranch Rd. Ste 100 <br />(909)484-0300 <br />CITY Rancho Cucamonga <br />STATE CA <br />ZIP 91730 <br />BILLING ACKNOWLEDGEMENT: 1, 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:_.. DATE: 1/15/14 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT In contractor/construction Mgr <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 />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me Or <br />my representative. - YAtQ <br />TYPE OF SERVICE REQUESTED: Vt ST <br />/TFCEN N% <br />COMMENTS: <br />3 <br />� ?0 <br />ACCEPTED BY: 1� <br />EMPLOYEE M <br />DATE: <br />4 <br />ASSIGNED TO: - CA C � <br />EMPLOYEE M / Z Z <br />DATE: <br />Date Service Completed (if already co leted): <br />SERVICE CODE: ) CI 0 <br />PIE: Z 3 U <br />Fee Amount: ?7'� <br />\IRPayment <br />Amount Paid <br />37� �� <br />Payment Date <br />3VI <br />Type <br />Invoice # <br />Check # 121Z2— <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />