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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 <br /> OWNER / OPERATOR <br /> Pilot Travel Centers , LLC CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Flying J #618 / Pilot Travel Centers , LLC <br /> SITE ADDRESS 1501 N Jack Tone Rd . Ripon CA 95366 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Rob Sills - Jones Covey Group , Inc . CHECK If BILLING ADDRESS <br /> BUSINESS NAME Jones Covey Group , Inc . PHONE # EXT, <br /> 714 975 - 4257 <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 : f�p �- 15 4P/J� DATE : 12/8/2022 <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 /> t0 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 : UST Repair Permit App <br /> COMMENTS : <br /> - UDC # 14 / 15 : Install Bravo Retrofit entry kits inside UDC <br /> -T-4 87 Annular L- 10 : Break ground and replace 4 " FRP riser, and replace 24 " manway . <br /> ANNULAR RISERS ALSO REPLACED AT : T- 1 DIESEL ANNULAR ( L4 ) , AND T-5 91 ANNULAR ( L- 11 ) <br /> ACCEPTED BY : EMPLOYEE #: DATE: <br /> ASSIGNED TO : EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed ) : SERVICE CODE : PIE : <br /> Fee Amount : Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />