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New�Iacilily xExistling Facility <br /> San Joaquin County Environmental Health Department ads E07 <br /> Application Form <br /> Facility NName <br /> Flying J 618 <br /> 51te Address city State 20, <br /> Jack T ne Rd Ripon CA 95366 <br /> APH `supervisor DIS#rlct <br /> Type of Service ❑AppliraUon far ❑comultmion 13 chatrge oa C]w dr 0 Repalrs or Remodel d C"" <br /> Requmted Operairrg Pehnit <br /> CcmmerLts An-Built 11 Mt f2024-Raplaced VR vacuum sensor(PIN;330020A63)using VR spare Paris kit tP+N-85720G-110d)bcatod Wide the E io-dlesal TranlAio.r sump, <br /> Like4or4ko ropLWA noru,As-BLIM 04il ET2025-Repiacad leak detector{PN;93 LD-200011 Wated tR n Dib i STP sump,Like-For-i*e ropracemaelc <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑6IUIng Patty EJ FacHlty Owner ❑facility Contact M Property owner 00 conlractcw 0 ArchiteV <br /> rrqulred <br /> ❑UlinR PhTty acillty Owner El Facility Contact raperty Owner 0 Contractor ❑Arrhltect <br /> FlrstName Pi lot TraveI Gemers L LC <br /> Lasrname If contractor,indicate type and lliensenumber <br /> A dr s Ckt tate ZIP <br /> 5508 Lonas Ddve noxville ITN 37909 <br /> Prune Phgne Emall <br /> ill Ing Party 0 Facility Owner 0 Fa€ilky Caritatt ❑Property Of7- <br /> Contractor ❑Archltect <br /> First dame LasR name pntract ,indicate type and I Icens¢number <br /> Albert Barajas 804431 <br /> 15ddfess aty 9595 Luca Ranch Road 4100 Ran State <br /> cho Cucamonga C �I <br /> A 91730 <br /> Phone Phorwe(909) 213-51266 A#6�tharaje jrpotfagroup <br /> PAY I <br /> NT <br /> Q Billing Party IJ Fadlity Owner ❑Facility Contact ❑Property❑rilrier ❑Contractorp rc i <br /> 1"�E L► 1+ <br /> First Name Last name If contractor,indlcate type a nd rlct-me nu tuber <br /> Address City State T.I <br /> ZQi IHTy <br /> Phone Phorie Email ENVIRON ENTAL <br /> HEALTH DE <br /> BILLINCr ACKNOWLEUGEM ENT.1.the underslened properly or bkLslrne59 owner,operrtor(w i WliorlreA agent of$a me.acknewledpe I hit all site andlor project <br /> spod0c ErmsoNWNTAL HEALTH DEPARTMENT houaly charges associated with Ihls project or actlwlty will be billed to me or my business as Identified on this <br /> farm. <br /> I also certINthat 1 have prepared this oppllcation and that the work to be performed wlli be done In accordance with all.SAN H]AQUIR COLD"Qrdlnance cads.. <br /> Standards,STATE and FEDERALm4x?.� DATE; 09130125 <br /> JaIrCAFFT'SSIGf�IATURE: laws. <br /> AP E; _ <br /> ❑PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑OTHER ALn?i4RIZED AGENT to Assistant Environmerlial Complia nee PM <br /> Title <br /> Jf APJ'LICAFFT ii not the BILLING PARTY,pdnnf of aiLrtholintion to sign IS requited <br /> AUTHORFEATION TO RELEASE I NFORMATION:WV ien apprlrable,k the owner or operator of the properly io€ated at the above site address,hereby authorize the <br /> feleaseof any arwd alf resultsrgeotechnkat data andfor erwirnnmentkI/site assessment Information to the SAN JOAQU1N 00UN7Y ENVIRONMENTAL HEALTH <br /> DEPARTh1ENT as soon as it is available and xt the same t1me A is provided tome ar My FelpresepitativeL <br /> PrA <br /> Accepted B Assign a ' r LJn7u!+d FA ID <br /> Date+ PE2- o Record rNuinber <br /> oall <br /> I 1IJJ r� Payment <br /> ❑Cash ❑Check f! Conllrm c cl <br /> ation# f! Reved 9y <br /> Rev 07f10{2024 �� '� !} <br /> , ff MIT <br /> 1 <br /> a ", I <br />