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SAN JOAQUO—OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICEREQUEST # <br />Stop <br />PHONE# ExT' <br />909 972-7581 xt. 205 <br />HOME or MAILING ADDRESS <br />9595 Lucas Ranch Road #100 <br />Gas Station/Truck <br />FAX # <br />( 909 ) 484-0300 <br />CITY Rancho Cucamonga <br />OWNER/ OPERATOR <br />CHECK It BILLING ADDRESS <br />Pilot Travel Centers LLC <br />FACILITY NAME Pilot -Flying J #617 <br />SITE ADDRESS-451tT— <br />N. <br />Thornton Road <br />Lodi <br />95242 <br />15Z Number <br />I Direction <br />Street Name <br />city <br />Zin 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 />( ) <br />BOS DISTRICT --lLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Holly Mendez <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Jones Covey Group, Inc. <br />PHONE# ExT' <br />909 972-7581 xt. 205 <br />HOME or MAILING ADDRESS <br />9595 Lucas Ranch Road #100 <br />FAX # <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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 10/7/2010 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT El 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.a <br />MILLIL11XIE1 <br />TYPE OF SERVICE REQUESTED: ✓t S -% �,? 1 C7r` ' E <br />COMMENTS: <br />OC1 11 210 OCT 11 2010 <br />HEALTH <br />SAsRRMIi%SERVICESE�oNAT <br />HEpL1H DEP <br />ACCEPTED BY: �� i �Q EMPLOYEE #: 0 3 Z DATE: o �� 1„o <br />ASSIGNED TO: ,t �` J` /1 f EMPLOYEE #: C F 2� _ DATE: lvO 1 / / ,'1 <br />Date Service Completed (if already completed): SERVICE CODE:�� PIE: 2�?ap <br />Fee Amount: 3�� �� Amount Paid 3 (o- Payment Date ® ?J <br />�� <br />Payment Type Invoice # Check # (� !, "� Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />