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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Fueling FacilityO 06 J , 00 S U I S (p 0 OWNER / OPERATOR Pilot Travel Centers , LLC CHECK If BILLING ADDRESS ❑ FACILITY NAME Flying J #618 / Pilot Travel Centers , LLC SITE ADDRESS 1501 N Jack Tone Rd . Ripon CA 95366 Street Number Direction Street Name City Zi HOME or MAILING ADDRESS (If Different from Site Address) /� / VE 7% Street Number Street Name , \ V D CITY STATE ZIP DEC PHONE #1 ExT. APN # LAND USE APPLICATION # SANZ�Z? ( ) NFEN /RO UlN 0 PHONE #2 EXT• BOS DISTRICT LOCATION CO4R Tq NT Y ( ) MENT CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS Rob Sills - Jones Covey Group , Inc . BUSINESS NAME Jones Covey Group , Inc . PHONE # EXT, 714 975 - 4257 HOME or MAILING ADDRESS 9595 Lucas Ranch Road # 100 FAX # ( 909 ) 484-0300 CITY Rancho Cucamonga STATE CA ZIP 91730 BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and /or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . 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 COUNTY Ordinance Codes, Standards , STATE and FEDERAL laws . APPLICANT'S SIGNATURE * 40� 5 016 DATE : 12/ 15/2022 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Jones Covey Group - Permitting If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me or my representative . TYPE OF SERVICE REQUESTED : UST F:k*0 f 4:L AMD V QY� U cle� COMMENTS : Pump #26 was damaged by a customer vehicle . We will replace the shear valves and perform precision line test on the product piping to ensure no leaks or damage to piping integrity . ACCEPTED BY: EMPLOYEE # : DATE: I2 20 n z� ASSIGNED TO : ✓1 EMPLOYEE # : DATE: Date Service Completed (if already completed ) : _1 SERVICE CODE: /i PIE : 14 1 25061 Fee Amount : 4 Amount Pai /5(,, b Payment Date Payment Type Invoice # Check # �5� 33SReceived By : G7 � EHD 48-02-025 SR FORM (Golden Rod ) 07/17/08