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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -Gas Station/Truck Stop ago Z 6,0/p <br /> OWNER/OPERATOR CHECK UPILLIN AQDR9881:1 <br /> Pilot Travel Centers <br /> FACILITYNAME Pilot )Flying J #618 <br /> SITE ADDRESS Ripon 95326 <br /> Jack Tone,�R city- I <br /> ,,,? a I Code <br /> 1501 Street Number 01IJ <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> st <br /> treet a4 <br /> root Number 1 14-! " <br /> CITY STATE zip <br /> ------ Lul't <br /> PHONE#1 ExT. LAND USE APPLICATIO114V <br /> T_P" <br /> PHONE#2 EXT. <br /> CONTRACTOR I SERVICE RE QUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Glenn Owens PHONE# EXT. <br /> BUSINESsNAME 972-7581 <br /> Jones Covey Group. Inc. -A8-8-L <br /> HOME or MAILING ADDRESS FAX# <br /> 9595 Lucas Ranch Rd. Ste 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 or <br /> 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 IaWS. <br /> APPLICANT'S SIGNATURE: DATE: 12/9/13 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER 13 OTHER AUTHORizEDAGENT [@ Contractor/Construction Mgr <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 above <br /> site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment Information <br /> 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 <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED T0: EMPLOYEE#: EDATE: <br /> CA)0_VL_Q__p <br /> Date Service Completed (if already completed): SERKE CODE: P1 E: <br /> Fee Amount: Payment Date <br /> 43 J <br /> Invoice# Check# q' Received By: <br /> Payment Type 44 Q <br /> 4- <br /> SIR FORM(Golden Rod) <br /> -02-025 <br /> END 48 <br /> A'7147rnp <br />