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El New Fad llty 0 Existing Fad fty <br /> tvads, <br /> San Joaquin Counter Environmental Health Department <br /> Application Feral <br /> Faclli[y Dame <br /> Flying J 618 <br /> SkeAddres% City Skate �tP <br /> 1501 N Jack One Rd CA 95366 <br /> APN super%Isor dlsbrkt <br /> Tyke of,er%iRe I_i Appllcatlon Ear ❑Consultation ❑Change of Owner 100 Repalrs or Remodel: 0 Other <br /> Rtqutsted Operating Petmll <br /> Comments Resepl cWting Bravo Blo-Olesol&no CnA peneirallon a[Bio-Diesel shed sump using Brave apoxy, <br /> If mobHlt Food SrL€ie or Uoenw Plate Numper VIN <br /> pumper truck <br /> Con#act Types O RIIIIng party ❑facility Owner ❑Facility Contact M Pfopertyr Owner M Contractor ❑ArchlWt <br /> required <br /> ❑Billing Party ❑fadlity Owner ❑Facility Contact Propetly Owner CJ Contractor ❑Architect <br /> First Name Pilot Travel Centers LLG <br /> last name If con tractor.indicate type and license number <br /> Address 5508 Loner Drive CJt state ZIP <br /> Inoxvlue 7h1 37909 <br /> Rhone Phone ErrWI <br /> Itil"Party ❑Fadlity Owner ❑Facility Contact ❑Property Contractor ❑Ar€hltect <br /> r <br /> fIimt Flarne Last name IFconvactor,Indicate type and license number <br /> Albert $arajas 804431 <br /> Address 95 Lucas Ranch Roe 100 Sze#noo Cucamonga CA <br /> State <br /> F 91730 <br /> Ph Lin C Phone mall ar�iaSRpr49�ouP <br /> 909 13-5 6 to <br /> Q Boling Party ❑facility Owner ❑FaclI.Aw Contact ❑Property Owner 0 Contrar-tar ❑ "tee[ <br /> FJrsL Name LAst narne Il contractor,indlcam wor �} <br /> Address City StateIJI� <br /> Panne Phone Small QUIN <br /> BILLING ACKNOWLEOGEMENY:Ir the undersigned property or IbLpalnessowner,aperatcwor authorized agent of same,acknowledge trr.9t a ! <br /> sperifle E NVIROMMENTAL HEALTH!DEPARTMf NT hourly Charges associated with this project or activity wilr be blll&d to m e or my buslness as iidentlfie <br /> ffMr <br /> farm. <br /> l a@so certify that I have prepared this appkatlon and thbt the%york to he perFormed will be done i n aocordance with all SAN JOAQU IN COUNTY Ordlgll to Codes, <br /> Smndardsr STATE and FEDERAL laws, <br /> APPUCANT'SSIGNATURE: DATE, 06/12/ 5 <br /> ❑PROPERTY f BU514YESS OWNER ❑OPERATOR f MANAGER ❑OTHERAvrKCRIZED AGENTM Assiatant Envirionmenlal Comp1lanoe PM <br /> T1tJe <br /> If APPLICANT k not the BI LLING PARTY,proof OF auMorltatlon to sign Is required <br /> AUrrHORIZATION TO RELEASE INFORMA13ON:Wren appllcaWe,I,the owilei or operator of the property Ioglted at the abosre site address,hereby authorize the <br /> release of any and all resutts,geotechnlcal data and/or envImnmentarlslte assessment 3nformsLion to the SAN)OAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTM EFT as soon as it IS avallable and at[ho same lime iL is r4yided to rgfi or m €e resentath+e. <br /> +,crept BY "nedT2 I UW dFAID <br /> Dale -7 PE aa 0 61 Fee �V --[Record Number # <br /> Ca C�Ish ❑Check lw {onfHnna#fan It Payment <br /> Rey O?1=04 <br />