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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fueling Facility i . �) [, CI a <br /> OWNER / OPERATOR <br /> Pilot Travel Centers , LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Pilot Travel Centers , LLC <br /> SITE ADDRESS Roth Road Lathrop 95330 <br /> 345 Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address ) 5508 Lonas Raod <br /> Street Number Street Name <br /> CITY Knoxville STATE TN ZIP 37909 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 800 ) 562- 6210 T I — —] <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 209 ) 5994141 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Jones Covey Group , Inc . CHECK If BILLING ADDRESS <br /> BUSINESS NAME Jones Cove Group , Inc . PHONE # EXT' <br /> Y P 909 ) 232 - 2997 <br /> HOME or MAILING ADDRESS Fax # <br /> 8595 Lucas Ranch Road # 100 <br /> ( 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 : DATE : 10/ 13/20 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor <br /> If APPLICANT is not the BILLING PARa 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 thsame time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED : UST Repair <br /> COMMENTS : OC r O <br /> Repair Underground Secondary Piping at UST Sump S4 At j / � 4 ?O <br /> yFg4Tti�o M� CO ?0 <br /> FAgR NTy <br /> ACCEPTED BY : LA4 /) ✓11 EMPLOYEE # : =DATE: 16 <br /> ASSIGNED TO : /.1 ` ^ EMPLOYEE # : DATE : 0 / v ' ' lt'J� <br /> All <br /> Date Service Completed (if already completed) : SERVICE CODE : I G1 P / E : <br /> Fee Amount : L11 a 54 Amount Paid STlO. 66DPaymenft Date <br /> do �b / e� <br /> Payment Type it Invoice # Check # IS50g�o7� Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />