Laserfiche WebLink
SAN JOAQUIN COUNTY k: l►>'VTRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # Sf RVICE REQUEST # <br /> Fueling Facility and Convenience (Oro skomOY2 <br /> OWNER / OPERATOR <br /> Pilot Travel Centers , LLC CHECK IfBILUNOADDRESS 13 <br /> FACILITY NAME Pilot Travel Centers , LLC <br /> SITE ADDRESS N Jack Tone Road Ripon 95366 <br /> 1501 StreatNumber DIF0511onr Cod <br /> HOME or MAILING ADDRESS (if Different from Site Address) 5508 Lonas Raod <br /> Street Number SlrostName <br /> CITY Knoxville STATE TN zip 37909 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 800 ) 562-6210 228- 110-230-000 <br /> PHONE #2 ExT, BOS DISTRICT LOCATION CODE <br /> ( 209 ) 5994141 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> ItEQUESTOR <br /> Jones Covey Group, Inc. CHECK If BILLING ADDRESS <br /> BUSINESS NAME Jones Covey Group , Inc. PHONE # ExT. <br /> 714 975 -4257 <br /> HOME or MAILING ADDRESS 9595 Lucas Ranch Road # 100 FAX # <br /> ( 909 ) 484-0300 <br /> CIN 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 end that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDFAAL laws . / <br /> APPLICANT' S SIGNATURE : DATE : 4 <br /> 1� ^ 1 1 <br /> PROPERTY I BUSINESS OWNERO OPERATOR / MANAGER O OTI{ ER AUTHORIZED AGENT ® Contractor <br /> If APPLICANT is not theLL/ �ING PARTY proof of authorization to sign is required Tlrle <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 environmentaUsite asW sment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Sam gt1% �t/j�c <br /> provided to me or my representative. /� ��f�/ PA <br /> P4 Xce <br /> TYPE OF SERVICE REQUESTED : kppficatiorrfe3t ST Removal Permit AllpCO <br /> COMMENTS: - REMOVE EXISTING 1 , 000 GALLONS DOUBLEWALL FIBERGLASS OWS OIL HOLDING USII r% <br /> N W1, //V A 9 <br /> " REMOVAL SCOPE OF WORK IS PART OF SEPARATELY PERMITTED REPLACEMENT OIL WATER DEpgR M <br /> SEPARATOR SYSTEM (NOT UST) VT <br /> ACCEPTED BY : V� EMPLOYEE #: DATE : 13 <br /> ASSIGNED TO: EMPLOYEE #: O DATE : b�n <br /> Date Service Completed (If already c p d) : SERVICE CODE: a3 P / E <br /> Foe Amount: Pq Amount Pald Payment Date 2, 3 <br /> Payment Type /1u Invoice # Check # 97 '3302- Recelved By: <br /> EHD 48-02-025 � U TA 4 �5� . 0Z) SR FORM ( Golden Rod ) <br /> REVISED 11 /17/2003 V <br />