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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 <br /> OWNER / OPERATOR <br /> Pilot Travel Centers , LLC CHECK IfBILLING ADDRESS ❑ <br /> FACILITY NAME Pilot Travel Centers , LLC <br /> SITE ADDRESS I Roth Road Lathrop 95330 <br /> 345 Street Number Direction 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 Ear• APN # LAND USE APPLICATION # <br /> ( 800 ) 562-6210 <br /> PHONE #2 Exr, 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 : 61moAcw CO�Koaa DATE : 10/ 13/20 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT IN Contractor <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 <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 s Iit is ;available and at; ib 7salve t ' pe it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED : UST Repair <br /> COMMENTS : <br /> Repair Underground Secondary Piping at UST Sump ) <br /> ACCEPTED BY: EMPLOYEE # : DATE: <br /> ASSIGNED TO : EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE : P / E : <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />