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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Fueling Facility DO ) Cy 7c7 OWNER / OPERATOR I Pilot Travel Centers , LLC CHECK If BILLING ADDRESS ❑ FACILITY NAME Pilot Travel Centers , LLC SITE ADDRESS 15237 N . Thornton Road Lodi TZip 5242 Street Number Direction Street Name Cit Code HOME Or MAILING ADDRESS ( If Different from Site Address ) Lonas Raod Street Number Street Name CITY STATE ZIP PHONE #1 EXT APN # LAND USE APPLICATION # ( ) PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Rob Sills - Jones Covey Group , Inc . CHECK If BILLING ADDRESS BUSINESS NAME .PHONE # E Jones Covey Group , Inc . 714 975 - 4257 HOME or MAILING ADDRESS 9595 Lucas Ranch Road # 100 FAX # ( 909 ) 484- 0300 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 , APPLICANT' S SIGNATURE : eeo hoe 5 616 DATE : 12/1 /2022 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Jones Covey Group - Permitting If APPLICANT Is not the BILLING PARTY, proof of authorization to Sign is required ed 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 . PA TYPE OF SERVICE REQUESTED : C// ec 'e/ var COMMENTS : SB989 Repairs - Replace product and electrical penetrations inside UDC ' s # 1 /2 & 5/6 . SANDEC 022o22 E �OAQUIN COU HEA VI pE ARTM N Y ACCEPTED BY: ,\ ! EMPLOYEE M DATE: Z ZZ ASSIGNED TO : ( V EMPLOYEE # : DATE: Date Service Completed (if already comp) ed ) : — SERVICE CODE : f I I P I E : 03 O Fee Amount : � / „ ` ' Amount Pai �S(O Payment Date 12. 2 Payment Type `— Invoice # Check # ) 53GZS223 ( Received By : EHD 48-02-025 SR FORM (Golden Rod ) 07/17/08