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SAN JOAA COUNTY ENVIRONMENTAL HEALT&PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYID# SERVICE REQUEST# <br /> Gas Station/Truck Stop t�' 0 b6 7 (z00 10 1bi Z3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Pilot Travel Centers <br /> FACILITY NAME <br /> Pilot Flying J #618 <br /> SITE ADDRESS <br /> 1501 N Jack Tone R?gd Ripon 95326 <br /> Street Number Direction Stree ame city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 Ex-r. BOS DISTRICT LOC,(1TION CODE <br /> 1[( ) I -1 <br /> POn <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSID <br /> Glenn Owens <br /> BUSINESS NAME PHONE# ExT' <br /> Jones Covey Group, Inc . (888) 972-7581 <br /> HOME or MAILING ADDRESS FAX# <br /> 9595 Lucas Ranch Rd. Ste 100 (9091484-0300 <br /> CITY Rancho Cucamonga STATE CA ZIP 91730 <br /> BILLING ACKNOWLEDGEMENT: 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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: --��'�., -- DATE: 12/9/13 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT In 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, I, 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: 0 Rt(` .E)vT <br /> COMMENTS: JqN <br /> 13 <br /> o� <br /> 0 <br /> ACCEPTED BY: r /1 f aj EMPLOYEE#: ? L) DATE: <br /> ASSIGNED TO: EMPLOYEE#: Q /"t DATE: <br /> Date Service Completed (if already complet ' SERVICE CODE: f P 1 E: 6 <br /> Fee Amount:q 2, "� �� Amount Pai �7SOb Payment Date <br /> Payment Type Invoice# Check# Gt Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />