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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Flying J Travel Center #618 � Pc 0 b U 66 ;5q.2 <br /> OWNER / OPERATOR <br /> Pilot Travel Centers LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Flying J Travel Center #618 <br /> S�5AADDRESS N . Jack Tone Rd . Ripon 95366 <br /> Street Number DIrectlon 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 /> ( ) <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Robert Sills CHECK If BILLING ADDRESS <br /> BUSINESS NAME P N EM' <br /> Jones Covey Group , Inc . 1E 975 -4257 <br /> HOME or MAILING ADDRESS FAX # <br /> 9595 Lucas Ranch Rd . # 100 ( 909 ) 484- 0300 <br /> CITY Rancho Cucamonga STATE CA ZIP 91730 <br /> BILLING ACKNOWLEDGEMENT : 1, 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, ST E and FEDE L laws , �7 1 <br /> APPLICANT' S SIGNATURE : DATE ; <br /> PROPERTY / BUSINESS OWNER 13 OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Jones Covey Project Support <br /> If APPLICANT is not theBILLINGPARTY, goof of al[t11orYzation to sign is regttired 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. self <br /> TYPE OF SERVICE REQUESTED : Permit Ap lic <br /> COMMENTS ' Application for permit to maI s related to overfill prevention testing . <br /> Replace drop tubes in tanks 1 , 41 5 , 6 0 <br /> nib ri ntity 5 drop tubes to be replaced . ) <br /> 5A� JC R�NME�ME�� ` <br /> 6N N pepl � .t <br /> 11 Ile <br /> .F7 tlr1� <br /> ACCEPTED BY: EMPLOYEE G� � I DATE:' - tl �lq l <br /> ASSIGNED TO: / EMPLOYEE #: DATE: — 2 � I C' <br /> Date Service Completed (If already Completed ) : SERVICE CODE: P 1 E: � )3 <br /> Fee Amount : Amount Paid 45 (0 co Payment Date I 3 t � <br /> Payment Type ►� Invoice # Check # Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />