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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEES,T '# Fueling Facility f� j� Q ?yc f �`� �'Q �gS '-1 Ulls OWNER / OPERATOR Pilot Travel Centers , LLC CHECK if BILLING ADDRESS FACILITY NAME Pilot Travel Centers , LLC SITE ADDRESS Roth Road Lathrop 95330 345 Street NumberDirection Street Name city ZID Code HOME or MAILING ADDRESS (If Different from Site Address) 5508 Lonas Raod Street Number Street Name CITY Knoxville STATE TN Zip 37909 PHONE #1 EXT* APN # LAND USE APPLICATION # (800 ) 562-6210 PHONE #2 EXT, BOS DISTRICT LOCATION CODE ( 209 ) 599-4141 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Bruno Espinoza - Jones Covey Group , Inc . CHECK if BILLING ADDRESS BUSINESS NAME Jones Covey Group , Inc . PHONE # EXT, ( 9091 543 - 8904 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 . 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 : DATE : 9/ 1 /2022 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT IS not the BILLING PARTY, 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or my representative . TYPE OF SERVICE REQUESTED : ��J �+ 644 COMMENTS : RECEIVEED Replace flex connector at Dispenser 7/8 , like for like , on 91 gasoline product line . SEP 0 9 1 41 02 SAN JOAQUIN Coti MTy ENVIRONMENTA HEALTH DEPARTAI NT ACCEPTED BY : L ��y. EMPLOYEE # : DATE: 2 �J ASSIGNED TO : �� `s"' � � EMPLOYEE # : DATE: Date Service Completed (if already completed) : _ __ SERVICE CODE: /9J _ �qt PIE : Fee Amount : , Amount Paid Payment Date Payment Type L] Invoice # # l (jaj Received By: �l� z z EHD 48-02-025 SR FORM (Golden Rod) 07/17/08