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SAN JOAQUI&UNTY ENVIRONMENTAL HEALTH 6ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station/Truck Stop <br />7i 17 9 <br />O� l fo�_ 2 -- <br />—OWNER <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />Pilot Travel Centers LLC <br />ACCEPTED BY: <br />FAx # <br />FACILITY NAME Pilot -Flying J #617 <br />EMPLOYEE#: 03 <br />( 909 ) 484-0300 <br />SITE ADDRESS 4510 <br />N. <br />Thornton Road <br />EMPLOYEE M I C F'Z7� <br />/CODE: <br />DATE: r 2� <br />Lodi <br />95242 <br />3,7 <br />P / E: 2-3© b <br />Fee Amount: If3 <br />Amount Paid 3 Co(.. 0'0 <br />Payment Date C7—r <br />Payment Type <br />I SS reet Number <br />Direction <br />Street Name <br />Received By: _ <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 339-4066 <br />PHONE#2 EXT <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />i j�l /1/ i� f �- PAYMENT <br />Holly Mendez <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />Jones Covey Group, Inc. <br />909 972-7581 A. 205 <br />HOME or MAILING ADDRESS 9595 Lucas Ranch Road #100 <br />ACCEPTED BY: <br />FAx # <br />EMPLOYEE#: 03 <br />( 909 ) 484-0300 <br />CITY Rancho Cucamonga <br />STATECA 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 JOAQU[N <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: �uk&of�-. DATE: 12/22/2010 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ®Environmental Compliance <br />If APPLICANT is not the B7LL7NGPAR TY, 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: �S "J <br />i j�l /1/ i� f �- PAYMENT <br />COMMENTS: <br />DEC 2 4 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />Li. V I- t 124 <br />EMPLOYEE#: 03 <br />DATE: 12_12-YF0 <br />ASSIGNED TO: <br />C-4 G <br />EMPLOYEE M I C F'Z7� <br />/CODE: <br />DATE: r 2� <br />Date Service Completed (if already completed): <br />SERVICE/ Iq / <br />P / E: 2-3© b <br />Fee Amount: If3 <br />Amount Paid 3 Co(.. 0'0 <br />Payment Date C7—r <br />Payment Type <br />✓ <br />Invoice # <br />Check # 6-3, <br />Received By: _ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />