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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Fueling Facility 117 dffl6,!; 9�. 4%Z =5L/ OWNER / OPERATOR Pilot Travel Centers , LLC CHECK If BILLING ADDRESS ❑ FACILITY NAME Pilot Travel Centers , LLC SITE ADDRESS 1501 N Jack Tone Rd . Ripon 95366 Street Number Direction Street Name City Zio Code HOME Or MAILING ADDRESS (If Different from Site Address) 4 A Street Number Street Name CITY LCSTATE v ZIP/ / PHONE #'i EXT. APN # LAND USE APPLICATION # ( 800) 562 - 621 0 X17* IQ -23 PHONE #2 EXT. [BOS DISTRICT LOCATIN CODE ( 209 ) 599 -4141 cis CONTRACTOR / SERVICE REQUESTOR REQUESTOR Jones Covey Group , Inc , CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT• Jones Covey Group , Inc . 951 ) 463 - 2800 HOME or MAILING ADDRESS FAX # 9595 Lucas Ranch Rd . ( ) CITY Rancho Cucamonga STATE CA ZIP 91730 BILLING ACKNOWLEDGEMENT : I, the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws . Dlgilaily signed by Margaret Davis DN: C=US, E=mdavis@jonescovey-wrn, 0='Jones APPLICANT ' S SIGNATURE : Margaret Davis ��zargaretiDavisOU=FuelConsWction, DATE : 10/08/21 Dale: PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor If APPLICANT is not the BILLiNGPARn proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I, the owner or operator of the property located at the above site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED : LISTP4 �2P�fi' / CE, COMMENTS : ocr 2 2021 SAN NEALTEJVVI Rp PMeNrU TY RTMENT ACCEPTED BY: r S f]1 EMPLOYEE # : DATE: ASSIGNED TO : 'Vj�/�( s �4 �ylaEMPLOYEE # : DATE: Date Service Completed (if already completed) : SERVICE CODE : ei /fAr( P / E : S Fee Amount: Amount Pai Payment Date l c� / Payment Type I Invoice # Check # /3366 7 ReceiveBy: EHD 4&02-025 SR FORM ( Golden Rod ) REVISED 11 / 17/2003