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FGSAN JOAQUWOUNTY ENVIR0NMP4rX1U3=U_X1ZW9PW <br /> SERVICE REQUEST E C 0 7 2016 <br /> Type of Business or Property __� �FA� fTy�# SERVICE REQUEST# q <br /> --Fueli�r g Flity —�- U �1 <br /> OWNER/OPERATOR <br /> Pilot Travel Centers, LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Pilot Travel Centers, LLC <br /> SITE ADDRESS N Thornton Road Lodi 95242 <br /> 15100 Street Number Direction Street Name FcityZip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 5508 Lonas Road <br /> Street Number Street Name <br /> CITY Knoxville STATE TN Zip 37909 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (800 )562-6210 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> (209 ) 339-4066 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jones Covey Group, Inc. CHECK If PILLING ADDRESS <br /> BUSINESS NAME Jones Covey Group, Inc. PHONE# Exr. <br /> 909 } 730-9185 <br /> HOME or MAILING ADDRESS 9595 Lucas Ranch Road#100 Fax# <br /> ( 909 J 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 changes 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 perfoim4d will be done in accordance with all SAN JOAQUiN <br /> COUNTY Ordinance Codes,Standards, TATE ant(F$D laws. <br /> APPLICANT'S SIGNATURE: " �L DATC: 12-7-16 <br /> PROPERTY/BUSINESS ONYNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> I,fAPPLICANT is not the BILLING AIRTY,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 environinentai/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: Penetration Repairs RFC EN <br /> COMMENTS: <br /> Remove and replace six (6) non-fiberglass penetrations with Bravo SWAT repair penetrations. <br /> H >�pON �.��Y <br /> EM' <br /> ACCEPTED BY; EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �C L� PIE: <br /> 01� <br /> Fee Amount: I I"f 62 Amount Pa 4/7D Payment Date <br /> Payment Type Invoice# Ch ck# d,3b/QU Received By: <br /> EHD 48-02-025 2 P_X® I J,� <br /> �^ SR FORM(Golden Rod) <br /> REVISED 11/97/2003 �" <br />