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RECEIVED JAN 1 22015 SERVICE REQUEST <br /> Type of <br /> Business or Pro a FACILITY ID# SERVICE REQUEST# <br /> V CJ { <br /> OWNER/OPERATOR <br /> Pilot Flying J LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Pilot Flying J #618 <br /> SITE ADDRESS N Jack Tone Road ' Ripon 95366 <br /> 1501 Street Number I Direction s cilyzI Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY %An) ZIP <br /> PHONE#1 EXT. APN# LAN C # <br /> PHONE#2 EXT. BOS DISTRICT. LOCATION CODE <br /> ( ) I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Jones Covey Group, Inc. CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME Jones Covey Group, Inc. PHONE# EXT• <br /> 88.8 972-7581 <br /> HOME or MAILING ADDRESS FAx# <br /> 9595 Lucas Ranch Road #100 <br /> (909 ) 484-0300 <br /> CITY Rancho Cucamonga STATE CA ZIP 91730 <br /> BILLING ACKNOWLEIIGEMENT: 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 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �} 2zz Jti---� DATE: 12/23/14 <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENTO Permits <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 <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 itis <br /> provided to me or my representative. L <br /> TYPE OF SERVICE REQUESTED: `J PAYMENT^ <br /> COMMENTS: U RECEIVED. <br /> JAN 0 2 2015 <br /> SAN JOAQUIN COUNITY <br /> 100ENVIROMENTAL <br /> HEALTH DEpARTME.HT <br /> ACCEPTED BY:. EMPLOYEE#: DATE: <br /> ASSIGNED TO: 0 EMPLOYEE#: DATE: <br /> Date Service Completed if already completed): SERVICE CODE: P t E.Xog <br /> Fee Amount: Amount Paid 3��,C� Payment Date <br /> Payment Type Invoice# Check# � �-qNZ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />