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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 0400 2q � C� o el <br /> OWNER / OPERATOR <br /> Pilot Travel Centers , LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Pilot Travel Centers, LLC <br /> www <br /> SITE ADDRESS N Thorton Road Lodi 95242 <br /> 145400 Street Number DIrection Straet Name CRY ZIP C <br /> HOME or MAILINo ADDRESS (If Different from Site Address) 5508 Lonas Raod <br /> Stroot Number ee Na <br /> e <br /> CITY Knoxville STATE TN ZIP 37909 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 800 ) 562-6210 <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 Covey Group, Inc . PHONE # ExT <br /> 888 972-7581 <br /> HOME or MAILING ADDRESS 9595 Lucas Ranch Road # 100 FAx # <br /> ( ) <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 . N y <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 JA* <br /> ^^1I 1 <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws . $/ L/ <br /> APPLICANT ' S SIGNATURE : a�Awcoo �a DATE : 05/26/2021 AN <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER O OTHER AUTHORIZED AGENT ® Contractor qN ✓ � 6 ?0Z, <br /> IjAPPLICANT is not the BILGING�wwwwwwPARTY, proof of authorization to sign is required Tit Fq V //"�� ' W IN CO <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property locateRT �NTy <br /> above site address , hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment Ph /VN <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 : UST Repair <br /> COMMENTS: <br /> Tank 44 & Tank # 5 — Fill Sump — Replacement of Existing Drop Tubes <br /> ACCEPTED BY: �) V EMPLOYEE M DATE : fJ / C <br /> ASSIGNED TO : EMPLOYEE #: DATE: <n / i �f <br /> Date Service Completed (if already completed) : SERVICE CODE: 4 11E : <br /> 2 <br /> Fee Amount: fj Amount PaidF Payment Date <br /> Payment Type Invoice # Check # Z Recei ed By: <br /> �Z� <br />