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SAN JOAQU#LINTY ENVIRONMENTAL HEALTOARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESST�# <br /> Gas Station/Truck Stop 000 66 � C 2 "yk�'o �q�' / 0 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Pilot Travel Centers <br /> FACILITY NAME <br /> Pilot Flying J #618 <br /> SITE ADDRESS <br /> N Jack Tone Rcd Ripon 95326 <br /> 1501 Street Number Direction Stree ame Ci 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 /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Glenn Owens CHECK If BILLING ADDRESSID <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 (909) 484-0300 <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 ® 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: <br /> COMMENTS: ? <br /> ACCEPTED BY: / J J EMPLOYEE#: 0 DATE: �- Z <br /> ASSIGNED TO: f AI EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: <br /> Fee Amount: 3 - Amount Paid ! S Payment Date <br /> Payment Type Invoice# Check# ZReceived By: <br /> EHD 48-02-025 �� SR FORM(Golden Rod) <br /> 07/17/08 �c 4t&4 )✓ L <br /> l <br />