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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE <br /> REQUEST # <br /> Fueling Facility dl �- cl7 SS 22 <br /> OWNER / OPERATOR <br /> Pilot Travel Centers , LLC CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Pilot Travel Centers , LLC <br /> 10 A <br /> SITE 52ADDRESS N . Thornton Road Lodi 952' E(�w If � <br /> YY <br /> Street Number Direction Street Name Cit Zi Code`' f� <br /> HOME or MAILING ADDRESS (If Different from Site Address) Lonas Raod SEP V 2D <br /> Street Number Street Name � n <br /> CITY STATE ZIP N JO `22 <br /> N ENS/ AQU/N <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # DEpqitNr,q ANT Y <br /> (209 ) 339 -4066 ENT <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Bruno Espinoza - Jones Covey Group , Inc . CHECK if BILLING ADDRESS <br /> BUSINESS NAME Jones Covey Group , Inc . PHONE # EXT. <br /> 909 543 - 8904 <br /> HOME or MAILING ADDRESS 9595 Lucas Ranch Road # 100 FAX # <br /> ( 909 ) 484-0300 <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 : 9/20/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Jones Covey Group - Permitting <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> 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 <br /> my representative . /,�' <br /> TYPE OF SERVICE REQUESTED : �( S T �e / r (/ "J� <br /> COMMENTS : <br /> T1 & T2 Siphon Line - Cut and disconnect the 2 " FRP primary pipe inside T1 STP Sump . Inspect for and <br /> remove any blockage in the line . Install new 2" BxM adapter and reconnect Siphon line . Repair located inside <br /> sump ( not breaking ground ) <br /> ACCEPTED BY : EMPLOYEE # : DATE: q Z2 � •I <br /> ASSIGNED TO : EMPLOYEE # : DATE: /ZZ Z•LJZ� <br /> Date Service Completed (if already completed ) : SERVICE CODE : / q f ,ZGq f P I E : 25 <br /> Fee Amount : � / (0 i? I <br /> Amount Paid ' DU Payment Date q122,12Z <br /> Payment Type t Invoice # Check # 45Z) 3 0 Receiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />