Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Pilot Travel Center F U%V O-7 54C% ')`—)S' f <br /> OWNER i OPERATOR <br /> Pilot Travel Centers LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Pilot Travel Centers LLC <br /> SIT1501DREss N• Jack Tone Rd. Ripon 95366 <br /> Street Number I Direction Street Name city Zlo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) PAS°&1E1V <br /> Street Number Street Name ���� <br /> CITY STATE ZIP <br /> SEP 2 <br /> PHONE#1 EXT• APN# -7 J LAND USE APPLICATION# <br /> (800 ) 562-6210 G p� U i �`` "L r °f E;'r . <br /> PHONE#T EXT BOS DISTRICT <br /> TC�( ) t7 c? LOCATION <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Robert Sills ## CHECK If BILLING ADDRESS <br /> BuslNEss NAME Jones Covey Group, Inc. ( 7N �4 975-4257 Exr <br /> HOME or MAILING ADDRESS FAX <br /> 9595 Lucas Ranch Rd. #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 <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: ' 5� C, DATE: 9-22-2017 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Jones Covey Project Support <br /> IfAPPLICANT 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 it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Permit Application Z <br /> COMMENTS: Application for permit to Install new underground conduits and Veeder Root wiring <br /> S F=P � 2, 201? <br /> ENV!R ON ,,1ENTA .E. _T i <br /> ACCEPTED BY: n ®a EMPLOYEE#: / DATE' tp I t <br /> ASSIGNED TO: EMPLOYEE#: DATE: CT a 5 <br /> -,a-5- <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P1 E: ?�� <br /> Fee Amount: f Amount Paid®�� Payment Date 1�a,5 X-7 <br /> Payment TypeInvoice# Ch # 1�®2-6/q3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />