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SAN JOAQUIN0OUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Pilot Travel Center F—P Ute Ta L 0�� <br /> OWNER/OPERATOR <br /> Pilot Travel Centers LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Pilot Travel Centers LLC <br /> SITE N. Jack Tone Rd. Ripon 95366 <br /> Street Number I Direction I Street Name citv Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) AY EN <br /> ECE . <br /> Street Number Street Name � I <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# Z J LAND USE APPLICATION# -Q vk CQ <br /> (800 ) 562-6210 <br /> PHONE#2 EXT. BOS DIS <br /> TRICT_ LOCATIOI�WDE <br /> 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Robert Sills CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHExT. <br /> Jones Covey Group, Inc. ( f� 4 975-4257 <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: ~s .'& DATE: 9-22-2017 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Jones Covey Project Support <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 <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 <br /> COMMENTS: 6 <br /> Application for permit to Install new underground conduits and Veeder Root wiring. <br /> ACCEPTED BY: E7Q 0- EMPLOYEE#: / DATE: �• <br /> ASSIGNED TO: v� Q_ EMPLOYEE#: 003) DATE: a•�c <br /> Date Service Completed (if already Completed): SERVICE CODE: (� PIE: <br /> Fee Amount: (,f 5 Amount Paid,UD Payment Date <br /> Payment Type/vld �i¢� Invoice# Ch # Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />