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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST APR 0 L >_ 112 's Type of Business or Property FACILITY ID # Fueling FacilityI OWNER / OPERATOR Pilot Travel Centers , LLC CHECK If BILLING ADDRESS ❑ FACILITY NAME Flying J #618 / Pilot Travel Centers , LLC SITE ADDRESS 1501 N Jack Tone Rd . Ripon CA 95366 Street Number Direction I Street Name Citv Zip Code HOME Or MAILING ADDRESS (If Different from Site Address ) 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 Jones Covey Group , Inc . PHONE # EXT. 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 . 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 : I A 516 DATE : 12/8/2022 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Jones Covey Group - Permitting If APPLICANT IS not the BILLING PARTY, proof of authorization to Sigh i5 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 : UST Repair Permit App COMMENTS : - UDC # 14/ 15 : Install Bravo Retrofit entry kits inside UDC -T4 87 Annular L- 10 : Break ground and replace 4 " FRP riser, and replace 24 " manway . ANNULAR RISERS ALSO REPLACED AT : T- 1 DIESEL ANNULAR ( L-7 ) , T-5 91 ANNULAR ( L- 11 ) , AND T-6 DIESEL ANNULAR L- 12 ACCEPTED BY : EMPLOYEE M DATE: ASSIGNED TO : EMPLOYEE M DATE: Date Service Completed (if already completed) : SERVICE CODE: PIE : Fee Amount : Amount Paid Payment Date Payment Type Invoice # Check # Received By : EHD 48-02-025 SR FORM (Golden Rod ) 07/17/08