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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 '%zok L/ <br /> OWNER/OPERATOR <br /> Pilot Travel Centers, LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Pilot Travel Centers, LLC nti, "04, <br /> SITE ADDRESS 1501 N Jack Tone Rd. Ripon 95366 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> "!4 Street Number Street Name <br /> CITY LCinql 4-0// STATE ZIP <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# 5•L7 <br /> ( 800)562-6210 <br /> PHONE#2 Eta. BOS DISTRICT LOCATI N CODE <br /> ( 209) 599-4141 U <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jones Covey Group, Inc, CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex-r. <br /> Jones Covey Group, Inc. 951)463-2800 <br /> HOME or MAILING ADDRESS FAX# <br /> 9595 Lucas Ranch Rd. ( ) <br /> CITY 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 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 /> Digitally signed by Margaret Davis <br /> DN:C=US,E=mdavis@jonescovey.ocm,0='Jones <br /> APPLICANT'S SIGNATURE: Margaret Davis Covey lnc.',OU=FuelConsWcticn, <br /> CN=Ma,ga,.tgaret Davis DATE; 10/08/21 <br /> Dale: - <br /> PROPERTY/BUSINESS OWNER IJ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> If APPLICANT is not the BILLINGPARn 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. - —n— A <br /> TYPE OF SERVICE REQUESTED: UST �ZPifl'�/� C�`, <br /> COMMENTS: <br /> ; SAN OCT 2 1 242 <br /> �AQUl <br /> NSA D PAa A L TY <br /> �N-r <br /> ACCEPTED BY:r f^jJ �vD� y� EMPLOYEE#: DATE: <br /> ASSIGNED TO: �S �� �+Q�vCo'��✓/ ' ! EMPLOYEE#: DATE: .�! <br /> Date Service Completed (if already completed): SERVICE CODE:17k <br /> i/fQf P/E, S <br /> Fee Amount: �— v C� Amount Paid/45III Payment Dav6tel! / <br /> Payment Type t Invoice# Check# /33�p // 7 Receive, By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />