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El New Facility YE=ilit <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Fa€Illly N ame <br /> Flying J 618 <br /> SILO Addreii City $late lip <br /> 1501 N ,hack T ne Rd Ripon CA 95366 <br /> APN 5upervlsu�fTlstrfc# <br /> Type of Service 0 AppIkAtlon for a Consullatl" ❑Change of Owner N Repalrs or Remodel C]Mer <br /> Rel:lLw red OperatlKrg Perm it. <br /> Comments lBruak oul€uwc;o on 1ho oxiepior or the Lab Shed,excayate,and feaeal the eAvkv UO Ala-dimeF line ow pene1raUpn to 0 p t,,nydlgn r ijnV <br /> W Io#tall il 50WWary UAMSheltUWpliAo oulslde of the Bio Styvd Traneilion Sump_ <br /> rFinablle food truck or T <br /> t•nscPiate Nfumbcr VIN <br /> p umper ftdC <br /> Contact Types 0 1111111m P" a Faelllty Owner 0 Faclilty Contact M Property Owner W Conkra€tor O Ardritea <br /> required <br /> ❑Billing Party D FaCglty Owner Q faclllty Contact APropcirtV Owner 0 Contnclar ❑ArchlteCt <br /> First Pfbme Pilot Travel Centers LLC <br /> Lasl name IFcontnctor,Indicate type and deers number <br /> Address L dw State ZIP <br /> 5508 Lonas Drive Knoxville TIC 37909 <br /> PhOhe hone Email <br /> Q Billing#arty Q Fadlhy Owner d FatHI%y 14dmtac[ ❑Prnper[y Owner Contrar6pr ❑Archltea <br /> Foss Name Last name IF contnS-or.Indicate type and lican5e number <br /> Albert Barajas 804431 <br /> MdreSS 9595 Lucas Ranch load 4100 City SF ate ZIP <br /> Rancho Cucamonga A 91730 <br /> Phone Phone Email <br /> .y1+�Y .y Ibort,baralarQ1polragrauR <br /> 66 <br /> ❑511IIn9 Partw 0 Facility Owner ❑Facillty Gnnira€t ❑Property Owner 0 Contractor 0 AtthltC <br /> luirm <br /> First Name Last flame If€ ritra€lor,I nd is ate type and Ilrx er rl�r <br /> kdL[rCLS City State 71P '+ <br /> Phone Phone 6e 411 I <br /> A � <br /> 61LLING ACKNOVUL EDGEM ENT;1,the undersigned property Dr huslness owner,oper-4toror duthorlted agent of Ohre,bcknnwfedgr that all site ' <br /> specie is ENVI RON ME NTAL HEALTH IDE PART M E NT ho urly cha rges associated wttl4 this pmjea or wlyo will be billed to me or hey$uil"m as Idenllf led an[his` Nr <br /> form. <br /> I also certify that I I)ave prepared th is a pplication ar.d that the work to be periformed wlrl be done In i=rdince with arl 5AN IOAQU:IN COUPM Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLXANT'SSIGNATURE: DAM 9104125 <br /> ❑PROPE RTY{BUSMESS�YWNEft C3 OPERATOR/MANAGER ❑QTH£R AUTHORIZED AGENT M Assistant Eff0ronmenial Compliance PM <br /> Trtle <br /> I f APPLICANT is nat the fit LUNG PARTY,proof pr auLhprlgatlon to Sign is required <br /> AUTHORIZATION TO RELEASE INfORMgTIgN;When appl1G1b1e,I,the owner or operator of the property IaTAled at the above site address,hereby aulhorixe[he <br /> release of a ny and all results,geotech nkcal data and/Or enwlfpnm erilaf/slte zisessment Infarmitlon to the SAN JOAQUIN COUNTY EWIRONhAENTAL HEALTH <br /> D E PARTME NT as soo n a s It Ls aUai(able and a t the same t irn P 6t is prrwided to mg pr My+lpreselltillVl. / <br /> Accepted By F 1 � L ,4551®ned To L }� { � Unked FA 1O f i tW 61;f` <br /> 72 <br /> ❑Ale PE Fee Re€aid Number <br /> �53. <br /> P2ymen; � <br /> ❑{ash ❑Check tl conikmrilon F o209.z1 7 2 By <br /> Rev QVIDMT4 ,2( <br />