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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fueling Facility �� O C) is `U�kewea <br /> OWNER / OPERATOR <br /> Pilot Travel Centers , LLC <br /> CHECKlfBILLINGADDRESS � <br /> FACILITY NAME Pilot Travel Centers , LLC <br /> SITEADDDRES X51' N Thorton Road Lodi 95242 <br /> II Street Number Direction Street Name CIN ZIP Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 5508 Lonas Raod <br /> Streat Number Street Nama <br /> CITY Knoxville STATE TN ZIP 37909 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 800 ) 562-6210 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 209 ) 599-4141 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Jones Covey Group, Inc . CHECK If BILLING AnDRESS11 <br /> BUSINEss NAME Jones Covey Group, Inc. PHONEExT. <br /> 888 972-7581 <br /> HOME Or MAILING ADDRESS 9595 Lucas Ranch Road #100 FAX # <br /> ( ) <br /> CITY Rancho Cucamonga STATE CA ZIP 91730 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent o <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with th ' <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 SA74WAQUIN �® <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. ��NN <br /> APPLICANT 'S SIGNATURE : DATE : y�FNV/ �,pU�o <br /> PROPERTY / BUSINESS OWNER 13 OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor Fp NTy� �Y <br /> If APPL/CANT is not the BILLING PARTY. proof of authorization to sign is required Title FNT <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 itis <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: <br /> ENVIRONMENTAL HEALTH <br /> !NT <br /> ACCEPTED BY: S ���/ �� EMPLOYEE #: DATE : <br /> ASSIGNED TO: r EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE: PIE : <br /> Fee Amount: 2 Amount PaidS� v� Payment Date 7 <br /> Payment Type ��- Invoice # Check # �6 747 r2I eceived By: <br />