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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT )(PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 909-730-9185 <br /> A <br /> C Facility Name Pilot Travel Centers LLC Phone# 800-562-6210 <br /> I <br /> L Address 1501 N.Jack Tone Road Ripon,CA 95366 <br /> 1 Cross Street <br /> T <br /> Y Owner/operator Pilot Travel Centers LLC Phone#800-562-6210 <br /> 0 <br /> Contractor Name Jones Covey Group, Inc. Phone# 909-972-7581 <br /> N Contractor Address 9595 Lucas Ranch Road#100 Rancho Cucamonga,CA 91730 CA Lic# 804431 Class/� B HAZ <br /> T <br /> A Insurer Everest National Insurance Company Work Comp# CA1002046161 <br /> ICC Technician's Name Roberto Plaza ICC# 8036194 Expiration Date 09/28/2021 j <br /> R ICC Installer's Name Roberto Plaza ICC# 8036194 Expiration Date 09/28/2021 <br /> I <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC V2,etc.) Installed <br /> i <br /> T UDC 24 Sat Gasoline <br /> A UDC 13 Diesel <br /> N j <br /> K <br /> l <br /> r <br /> i <br /> P ❑ Approved ❑ Approved with conditions C Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN I <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> pplicanl'sSignature Title Project Su port Date 19—/.l 61 La L <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAMEJones Covey Group-Andrew Garcia TITLE Project Support PH0NE#C3$33 j7Z' 7%qI C4- T,73 <br /> ADDRESS 9595 Lucas Ranch Rd. #100, Rancho Cucamonga, CA 91730 <br /> SIGNATURE DATE IZI Z 6 !zn I q <br />