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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST FACILITY ID # SERVICE REQUEST - # Type of Business or Property c 1p QQ 1 S �I a -3 Travel Center with Quick Service Restaurant J � OWNER / OPERATOR CHECK if _BILLING ADDRESSO Pilot Travel Centers LLC Ryan J. Robinson FACILITY NAME Pilot Travel Centers Ripon, CA 95366 SITE ADDRESS 1501 North Jack Tone Road zi code Cit Street Number Direction Street Name Lonas Dr HOME or MAILING ADDRESS (If Different from Site Address) 5508 Street Name Street Number STATE TN ZIP 37909 CITY Knoxville LAND USE APPLICATION # PHONE#1 EXT. APN# 22811023 ( 865) 474-2935 LOCATION CODE PHONE #2 ExT. BOS DISTRICT CONTRACTOR /SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS Pilot Travel Centers LLC - Ryan J. Robinson PHONE # Err. BUSINESS NAME Pilot Travel Center 865 474-2935 FAx # HOME or MAILING ADDRESS 5508 Lonas Dr ( ) CIT`( Knoxville STATE TN ZIP 37909 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 a RAL laws. APPLICANT'S SIGNATURE: DATE: 10/5/2019 PROPERTY /BUSINESS OWNER OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 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 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 my representative. b. TYPE OF SERVICE REQUESTED: COMMENTS: /0/-7/19 0 `.7 // 9 (0 0 M�NT�t1l wde 4 TiyF ACCEPTED BY: EMPLOYEE #: Z DATE: (' ASSIGNED TO: EMPLOYEE #: V v DATE: Date Service Completed (if already com eted): U SERVICE CODE: [: rte?, Pi E: Fee Amount: Amount Pai S� v(� Payment Date I r4y111enr I ype I InVO1Ce # I CffeCk #2 `�/ �'3 % I Receibed By: /�(�� I EHD 48-02-025 `J /(� / /�_ REVISED 11/17/2003 SR FORM (Golden Rod)