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❑ New Facility ® Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Flying J 618 Site Address City State ZIP 1501 N Jack Tone Rd Ripon CA 95366 APN Supervisor District Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner IN Repairs or Remodel ❑ Other Requested Operating Permit Comments To to replace (2) leaking flex connectors located in Bio Shed Transition Sump (1-2) and Diesel Transition Sump (1-8). If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑ Billing Party ❑ Facility Owner El Facility Contact N Property Owner IRI Contractor ❑ Architect 7 required ❑ Billing Party ❑ Facility Owner ❑ Facility Contact Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number P% IcA Travel Y4 LL Address 5508 Lonas Drive City State ZIP Knoxville TN 37909 Phone Phone Email Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner 04 Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Albert Barajas 804431 Address 9595 Lucas Ranch Road #100 city State ZIP Rancho Cucamonga CA 91730 Phone Phone Email 909 213-5266 �comAlbert.barajas@jfpetrogroup ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and JiGe s u C� Address City State ZIP Phone Phone Email S N J 2025 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge L specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identi i ANT form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 01/06/25 ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Assistant Environmental Compliance PM Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By Assigned To Linked FA ID 0 cu 4'm A1 Date. ' O� Fee Gv Record Number P� 1 . 2 a50 -7 a. ElCash ❑ Check# AConfirmation # l l 21 7 C�.� Payment I Received By Rev 07/10/2024