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SAN JOAQUI*OUNTY ENVIROr-4MENTAL HEALTHCPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station/Truck ,'Stop l, 179 .5"0(4p�2 /g I— <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Pilot Travel Centers LLC <br /> FACILITY NAME Pilot-Flying J#617 <br /> SITEADDRESS 15237 N. Thornton Road Lodi 95242 <br /> Street Number Direction Street Name city Zin 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 /> (209 )339-4066 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Holly Mendez CHECK If BILLING ADDRESS X <br /> EXT. <br /> BUSINESS NAME Jones Covey Group, Inc. P 888# 972-7581 205 <br /> HOME or MAILING ADDRESS FAX# <br /> 9595 Lucas Ranch Road#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: `j�'a�� ��fi DATE: 5/6/2011 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Environmental Compliance <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: UST rXlOG/T <br /> COMMENTS: <br /> MAY 12 201t <br /> �.,-UN COUNT'f <br /> .I�G td I„5 E Pd'TA.L <br /> HE1-ail H DEPARTMENT <br /> ACCEPTED BY: (A.) EMPLOYEE M ?,0%J 0DATE: Q S 2- ao J/ <br /> ASSIGNED TO: GJ T EMPLOYEE#: /70- DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7 6 P/E: .1-30 <br /> Fee Amount: 3 le G 00 Amount Paid 3 _ Payment Date 5 I <br /> Payment Type Invoice# Check# 11 Zq Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />