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SAN JOAQUI OUNTY ENVIRONMENTAL HEALEPARTMENT <br /> SERVICE REQUEST TW <br /> Type <br /> }of Business or Property FACILITY ID# SERVICE REQUEST# <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 /> ITE A 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 /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Jones Covey Group, Inc. CHECK If BILLING ADDRESS El <br /> BUSINESS NAME Jones Covey Group, Inc. PHONE# E"T• <br /> 888 972-7581 <br /> HOME or MAILING ADDRESS 9595 Lucas Ranch Road #100 FAX# <br /> (909 ) 484-0300 <br /> CITE' 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 22�4�1 �� DATE: 12/23/14 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Permits <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. L <br /> TYPE OF SERVICE REQUESTED: % NT <br /> COMMENTS: U RECEIVED <br /> JAN 0 2 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: 2- 11 t;7 <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j P 1 E: <br /> Fee Amount: Amount Paid 3�b.OrO Payment Date 2 �5 <br /> Payment Type _ Invoice# Check# �Z� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />