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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 �� oa2 � q �` � 00 00H <br /> OWNER / OPERATOR <br /> Pilot Travel Centers , LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Pilot Travel Centers , LLC <br /> SITE ADDRESS 345 1 Roth Road Lathrop 95330 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 5508 Lonas Road <br /> Street Number Street Name <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 ) 599 - 4141 <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 /> 951 )463 - 2800 <br /> HOME or MAILING ADDRESS FAX # <br /> 9595 Lucas Ranch Rd . ( ) <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 /> Di 1&y signed by Margaret Da%tis <br /> Mar DN: C=US, E=mdavis@ onesmvey.mm, wiones Covey <br /> APPLICANT ' S SIGNATURE ga ret Davis Group,Ine', CU=FuelConsbuctlon, CN=MargarelDavis DATE 08/27/21 <br /> Date: 2021.08.27 16 14 08-oTW* <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor <br /> If APPLICANT is not the BILLLVGPARZZ 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 the same time it is <br /> provided to me or my representative . PA <br /> TYPE OF SERVICE REQUESTED : UST Repair ' h t. raDl <br /> COMMENTS : <br /> Replace OFP drop tube , like for like . Seg Q <br /> SgN �0 <br /> N�ALT <br /> 4 <br /> 0 MFNo�NrY <br /> � RPAq � <br /> ACCEPTED BY: EMPLOYEE # : DATE: <br /> ASSIGNED TO : let <br /> "[ tv EMPLOYEE # : DATE: V/ <br /> Z4 <br /> Date Service Completed (if already completed) : SERVICE CODE: 1 cp - tela P / E :�200 <br /> Fee Amount: �-�J� C'ZI Amount Paid �F� Payment Date <br /> Payment TypeL! R � � Invoice # Check # 13�G� Recei ed By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />