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13 New Facility 9 Existing Facility <br /> r " <br /> San Joaquin Counter Environmental Health Department <br /> Application Form <br /> Fa€ifity Name <br /> Fly[rg J 618 <br /> Site Address -- CILy State ZIP <br /> 1501 N Jack Tone Rd Rionrl CA 9 366 <br /> APN Supervrsar District <br /> Type of service 0 ApplkaHun far 0 consultation ❑Change of Owner (4 Repalfs ar Rernoder ❑Other <br /> RCquested Opegating Perinit <br /> Comments AS.9u16I OY+151Z5,WRW5,0WW25,D3ri 7fd5,C W V25,OYISV75.%placed(7 M leaking IFex mrineciom located in Elio Shed Trerrsllkon Sump. <br /> ($}leaking pay aonneolors In the S,f lee TramItlan Sump(I.1 Dl.and(1)leaking ReA case wws in 1hu R.Queer Tfon3ilion Sunv"I <br /> if mobile food trick or tkense Prate Number YIN <br /> C"Uarct Types 0 allrlt+g P.W" ❑Faclllty owner 11 FadIICy Contact 0 Fraper[y owner M Con1 radar ❑Archl tect <br /> required <br /> ❑fillllnit Party M FacNltY Owner Cl Faclllty i:0nrAC1 PrOKWtV OWnf r ❑Cum ractor ❑Architect <br /> first game Pilot Travel Centers LLB last name If contractor,Indic4te twe and Ilaeme number <br /> Addreu 5508 Lonas Drive �l no Ville Slaw <br /> 97909 <br /> Ph on a phone Email <br /> BUIIng Party ❑Facility Owme.' 11 facility Cantatt ❑Property Owner )(Contractor }, ❑Architect <br /> Ir <br /> Fiat Name Gast name If contracVw,Indicate type and Ilo mw number <br /> Albert Barajas 804431 <br /> Address CLty 9595 Lucas hunch Roach #1001III Rancho Oucan-ionga sCA 91730 <br /> r zIP <br /> phone Phpnr mrt <br /> 90 21 -5266 .bagajesjfpe[rogranip <br /> ' l Billing Pa 11 V q Facillty Owner ❑Facility Canta€t 7 0 Property Clwrler O Contraexar Ll Archltect <br /> FJrst Name, Last name If contractor,i ndicate type and license number <br /> Address City Skate XIP <br /> Phone Phone Emalt <br /> KRUNG ACICNOWLEWSIVIW.I,the L117ttervIgned properlyW business coiner,operaWr or authotrted agenl of same,acknowledge that all site and/or project <br /> specific ENVIAONMEN1'AL HEALTH DEPARTMEW houriV druEesassocaated with thiS project at activity will be bllled to me or my business.as Identifled an this <br /> form, �a <br /> I alPA M EN Tpared thlS appllcatlon and that the work Co be performed will be done In aocordan€e with all SAN JOAQL11N COUNTY Ordinance Codes, <br /> SCAP R—AL aws, Ad—e-1E214'ek DATE, 04108fgNpm <br /> Mim- V,��D <br /> ❑PR F l Eg 5I202rNER ❑OPERATOR JMANAGER ❑OTHER AUTHORIZE D AGE NT93 AsalslantEnvlr nmen l <br /> Trtie <br /> IrAPPLICANTi5 nut tlicBILHNG PARTY,proof ofauthorizationtoSign Is,required A 14 ']�'�'� <br /> $Aj*dQ QbW(QQ 40NFORMATFON.When appilcahle.I,the owner og aperarar of the propertVto€a[ed at the above site acidfe�s, erg WA i khe <br /> re-I Al VO 1',} ate€hnlcal data an d/or environmental/site asselsment InfonnaLion to the SAN 1CUsWIN COU �LINI S� 1R�JI MM€EFT ❑}i1 <br /> k*AkW0�i ailahke and at[he Same time it is provided to me or my representative. ""' P "" SE '—�� LTH <br /> psi rTr � <br /> ACC2pCgQ y Y Riylrl2d To F ` Linked FA Ili , +_ <br /> Q1t [ry44 PESI�'+rf F 1� Racord NumberVU <br /> { <br /> .5g9 <br /> PQ <br /> ❑ a fly ❑{heclr# 113'CUMIFMation p yinRnt <br /> f i R relVed�y <br /> lkeu 97/101262i <br />