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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 r=�- O2 (f �� n �)� � <br /> OWNER / OPERATOR <br /> Pilot Travel Centers , LLC CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Pilot Travel Centers , LLC <br /> SITE ADDRESS Roth Road Lathrop T95330 <br /> 345 Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5508 Lonas Raod <br /> Street Number Street Name <br /> CITYKnoxville STATE TN ZIP 37909 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> (800 ) 562-6210 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 599 -4141 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Rob Sills - Jones Covey Group , Inc . CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE # EXT. <br /> Jones Covey Group , Inc . 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 ofPAMMENT <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this pr9KEIVED <br /> activity will be billed to me or my business as identified on this form . AYP 1 12023 <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SA Q IN <br /> COUNTY Ordinance Codes, Standards , STATE and FEDERAL laws . SAN JOAQUIN COUNTY <br /> �I ,, ENVIRONMENTAL <br /> APPLICANT' S SIGNATURE , 009"T DATE : 8/9/23 HEALTH DEPARTMENT <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <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 : 14 ST R 1 <br /> COMMENTS : <br /> Repair and Retest failed T1 87 Leak Detector - Per inspection notice on 8/8/23 corrective action . <br /> Scope : Replace turbine controller to resolve and perform leak detector test . If leak detector failed after controller <br /> repaired , will replace leak detector also , PN : (Vaporless ) 99- LD2000 <br /> ACCEPTED BY: �} /f� [� I�A ✓moi EMPLOYEE # : DATE : O 02 <br /> ASSIGNED TOt—jQ EMPLOYEE # : DATE : �Q 3 <br /> Date Service Completed (Ifalreeadycomplletted ) : SERVICE CODE: / 2� � PIE : <br /> Fee Amount : 19 /�� Amount Paid �_ Payment Date Z <br /> Payment Type `Gj Invoice # Check # ,? g Received By : eK <br /> EHD 48-02-025 ( Z " SR FORM (Golden Rod ) <br /> 07/17/08 <br />