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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Fueling Facility fA Do Ry 7cl 6 W OWNER/OPERATOR Pilot Travel Centers, LLC CHECK If BILLING ADDRESS❑ FACILITY NAME Pilot Travel Centers, LLC SITE ADDRESS 15237 N. Thornton Road LodiF95242 Street Number Direction Street Name Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Lonas Raod Street Number Street Name CITY STATE ZIP PHONE#1 EXT, APN# LAND USE APPLICATION# ( ) PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Rob Sills -Jones Covey Group, Inc. CHECK If BILLING ADDRESS BUSINESS NAMEPHONE# E . Jones Covey Group, Inc. 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: ey 441t 5 11& DATE: 12/1/2022 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E Jones Covey Group-Permitting If APPLICANT Is not the BILLING PARTY, /hoof of authorization to Sigh is required ed 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. PA TYPE SERVICE REQUESTED: r f�v� Plan � ECE J IV COMMENEN TS: OEC SB989 Repairs- Replace product and electrical penetrations inside UDC's#1/2 &5/6. 02 2022 SAN JOAQUIN HEgLTy DE qR � Y ACCEPTED BY: f— i' I EMPLOYEE#: DATE: Z 2� ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already comp) ed): — SERVICE CODE: PIE:��O Fee Amount: �/„ Amount Pai �Sro Payment Date 12 2 Payment Type Ck', ` FInvoice# Check# JS3 to(�52-3 ( Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08