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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 O( O /,�, /..., - <br /> �/ (U1 • W <br /> OWNER / OPERATOR `-'+ ` <br /> Pilot Travel Centers , LLC CHECK if BILLING ADDRESSO <br /> FACILITY NAME Flying J #618 / Pilot Travel Centers , LLC <br /> SITE ADDRESS 1501 N Jack Tone Rd . Ripon CA 95366 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address ) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> t ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Rob Sills - Jones Covey Group , Inc . CHECK If BILLING ADDRESS ■ <br /> BUSINESS NAME Jones Covey Group , Inc . PHONE # EXT, <br /> 714 975 - 4257 <br /> HOME or MAILING ADDRESS 9595 Lucas Ranch Road # 100 FAX # <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 or <br /> 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 : eloP, �i2* e& DATE : 12/8/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT Jones Covey Group Permitting <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : R NT <br /> COMMENTS : ED <br /> - UDC # 14/ 15 : Install Bravo Retrofit entry kits inside UDC DEC Q8 <br /> SAN , 22 <br /> -T-4 87 Annular L- 10 : Break ground and replace 4 " FRP riser, and replace 24 " manwelV EN IAQU/N <br /> �IEALTy pEpq � TY <br /> NT <br /> ACCEPTED BY : e i np i1/ EMPLOYEE M DATE : •-7 <br /> L <br /> ASSIGNED TO : / EMPLOYEE # : DATE: / � z <br /> Date Service Completed ( if already completed ) : — SERVICE CODE : 1 (17.2q7, <br /> Fee Amount Amount Pai S Payment Date J �22 <br /> Payment Type Invoice # Check # ZW�:y t Received By : <br /> 153 `173191 <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />