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SAN,J000UIN Environmental Health Department SAN JOQOUIN EnvlronmentalHealthDepertment
<br /> —COUNTY—
<br /> Kinsey Foley,RENS,Interim Director —COUNTY---
<br /> „„ Greotncss grows here. PROGRAM COORDINATORS
<br /> 0.obx MCCbibn,REHS
<br /> ba CnrceencR,RENS,ROI e. A valid,current contractor's license Issued by the Contractors State License Board,
<br /> vwoy Na.REHS and
<br /> \tun. I Kb.REHS b. A valid,current UST InstallationlRetrofittin certificate issued b the International
<br /> Mirl Ne...RENS 9 y
<br /> Melkee NiMkn.RENS Code Council(ICC),and
<br /> Janus 15,2020 c. A valid,current certificate of training from the mahufacturer(s)of the component(s)
<br /> ry being installed.
<br /> ANDREW GARCIA
<br /> JONES COVERY GROUP,INC. 6. The tank owner or operator shall log Into the California Environmental Reporting System
<br /> 9595 LUCAS RANCH RD.0100 (CERS)at http://carscalepa.ca.gov/and ensure all UST information is current.
<br /> RANCHO CUCAMONGA.CA 91730
<br /> SR0081633 7. All components must be certified by an independent testing organization and labeled as
<br /> Re: Flying J travel Center LLC 0618 required by the organization(UL,ULC,ANSI,API,ASTM,etc.). See California Code of
<br /> 1601 N Jack Ton.Rd, Regulations(CCR)Title 23,Chapter 16,Table 8 for a complete list.
<br /> Ripon,CA 96366 8. Permit expires 180 days from the date of approval. If an extension to the expiration date
<br /> is required,a written request must be submitted to this office prior to the expiration date.
<br /> The San Joaquin County Environmental Health Department(EHD)has completed the review of
<br /> the application for a one hour plan check service to replace penetration fittings in UDC 13 and If you have any further questions,please contact me at(209)468-0216.
<br /> UDC 24 satellite for the underground storage tank(UST)system at the above noted address.The
<br /> permit has been approved with the following conditions. Thank you,
<br /> 1. Contact the local fire department and the San Joaquin Valley Air Pollution Control District
<br /> for any applicable permits and requirements. DU�
<br /> 2. Any changes in information and scope of work must be submitted to EHD for approval
<br /> prior to commencing work.All new addenda supersede the previous ones. SAeWB WoWea reg°y EHS
<br /> Environmental Health Specia9N
<br /> 3. Provide written notification to ustasigov.org or contact Shewi!Woldearegay at(209)468-
<br /> 0216 to arrange the following appointments(a 48-hour notice is required for inspection
<br /> appointments).Please be aware that inspections for emergency work must be scheduled cc:JOEYCUPA JOEYCUPPCPILOTTRACELCENTERS.COM
<br /> within five days of permit approval.
<br /> a) Visual inspection of the penetration fittings/piping within the UDCs for any leaks
<br /> 4. Any individual performing the work of a service technician must meet the following
<br /> quali ications •..,Vreo ' -, i ev
<br /> a. Possess or be employed by a person who possesses one of several permissible valid,
<br /> current contractor's licenses issued by the Contractors State License Board(may be w;• r
<br /> issued to the installation company),or a Tank Testers license issued to the individualI 53.
<br /> by the Stale Water Board,and
<br /> b. Possess or work under the direct and personal supervision of an individual physically Ory(T
<br /> present at the work site who possesses a valid,current California UST Service
<br /> Technician certificate issued by the International Code Council(ICC),and „1 L
<br /> c. Possesses a valid,current certificate of training from the manufacturers)of the t
<br /> components)being tested,repaired,or serviced. 1
<br /> 5. Individuals installing underground storage tank system components must possessorN
<br /> work under the direct and personal supervision of an individual physically present at
<br /> the
<br /> work site who possesses all of the following:
<br /> EN�TRoFns, Tnn�N
<br /> zaz
<br /> 1868 E.Hazelton Avenue I Stockton.California 952051 T 209 468-34201 F 209 466-0138 I cornu a,ev.wvDi n lxl w/�1969 E.HO %xn Avenue 181Ocklon,CAifix is 952031 T 200 4668-342D I F 209 464-01381 wRw.sjaehd.mm
<br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPAHTINLMI'
<br /> SERVICE REQUEST ENVIRONMENTAL HEALTH DEPARTMENT
<br /> Typeoreurbenor Propely 'iACKrt1'IDs Ia186Caa1011YT11
<br /> Flying J Travel Center 0618 lIGCllG/i' S`�00 - SANJOAQUWCOUNTY
<br /> owNu/D..— 1888 E.Hazelton Ave.,Stockton,California 95205
<br /> Pilot Travel Centers LLC O'CL a"0 O°°r° Telephone:(209)46&U20 Fax:(209)468-3433
<br /> FAmmxaelf Flying J Travel Center 6618 APPLICATION FOR UNDERGROUND STORAGE TANK
<br /> N. Jack Tone Rd. "I A 95388 RETROFIT OR PIPING REPAIR PERMIT
<br /> aAPmwArwre morAre n.lMrmcaDOW
<br /> WI
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<br /> CITY 6TMa M �.Cy E F EPA sNeY P1*d Cxnsd6TW h—# 909-7303185
<br /> nnEn a. ArNY wevn AT+uumneft
<br /> Fad11YNeme Pilot Travel Centers LLC Phones alio-562-6210
<br /> e
<br /> ISM)582-6210 JQN I Ed Ammo 1501 N.Jack Tone Road Ripon,CA 9539°
<br /> rxanN en. oa Parncr an 1Oz0 1 cmisseee1
<br /> { e kI,F R llyc Nr Y OewflimmbT P9ot Travel Canters LLC PhpneY 800-SB2ffi10
<br /> CONTRACTOR/SERVICE RE UESTOR pPARr Az P c conk.exe come Jones Covey Group,Inc. Ph—#909-972-7581
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<br /> Qu1❑x MAT i Ca.alaAddlaaa aetl Ller MSl,aw4ar4o Rene Oewsp.OAOU.p CAflue 804431 Ciaaa/hgF{AZ
<br /> Andrew Garda —'It.we AoowIt N�f1� I..EE EverestNationallnsunexesCompany Work C4mDY CA100204ini;Jone6 Covey Group,InC. /14 975-4257 r� r ICCTaeMklanlNRme Roberto P1a28 ICCI 8036199 F�kelbl De.09/28/2021
<br /> Fue ICC MIa6ah Nona Roberto Plana ICCI 8036199 EptlmOeb 09/28/2021
<br /> RBnCh Rd.X100 {9091484-0300 reek syabm we,,ane Tnk she CMmbals stead Cunenly -1.UBT
<br /> Rancho Cucamonga e - CA v 91730 e.a.ww...raa.weAl.e w.+el healed
<br /> EILI.INC ACKNOWL6UGEMENT:
<br /> I.
<br /> the uNe 'eel preii n brWu owner,eperllur Or suAorleN 1prel or lura, T UDC 24 Sat Gasoline
<br /> erknowledRe Mal all.il<eM/ur pmjccl 1p«ifw Elrv..—.Tu!{e.ktnr DerAerksrxr hourly ciurpn sswcirbJ wish Ihiv prnjccl A UDC 13 Diesel
<br /> or ectivi ly will be billed to me ur my bullneu as idemi6N on this form. 4.
<br /> 1 also nn.v STAT
<br /> M
<br /> +J
<br /> rc 0,xinal I have prcporcJ Ihu.STAT icn and M.I the cork to be pafomwd will M dew M—.,d—.—.,d—.wish.11SAN 1r,A0Ulx
<br /> n11NTy O
<br /> CCnJn,SmnJo.Jr, mJ vuL laws.
<br /> APPLICANT'S SIGNATURE:
<br /> "I
<br /> 12'26-2019
<br /> rxertilUTaxulG NUx13 OrtaArwlMAlu,.ae 13 OrxaI—OUIX.A.—M J""
<br /> Covey Pmlept Support%
<br /> I/Arp[rciNrli xor rM1e air r+ori P.reTT.p—ilefIIlAarhol/an lu Nax4 N,,Wnd P LI AwNxNNJ U Approved vAM oxxIMona EDleeppmed
<br /> AUTNORITATION TO RlLEASE INFORMATION:When applicable,1,Me owner ee epeexo,ur We propffQJ, 172 (Sas Adeehllbnl Wllh Cmdllbnel
<br /> .hove h.eddresr,hereby aedxxi,,e Me rcleasc a/ee,172 ail NeAl.,grolcehninm d.a 1R1w envi many N ft.R.1
<br /> Nemo Dete
<br /> m"'w Ih< AN IOAQUIn CO—Ex,_e ODTru.I{EALTII UerAaTMertt M noon d i dhYi9tlb N.
<br /> provided to me w nsy np—listive. _
<br /> urxwe OF eel
<br /> T-Or DeRvxE Rfcunm: / - Q ;1 __ o+nERoRLDEx wuiuneoseNn[rain coo TNArx
<br /> _ Paali�..surD.I sxnuiwo
<br /> neOr TIE wwF� MerceAUlfnlseUEO,I xWEAWOV P�eRaw+a elmEOEwoRa�lWAigx�u e
<br /> C°"'m'"`To perform SB989 Repairs on UDC 13 d UDC 24 Sat. E9b1VIRN IdPJ17,F wonxw s
<br /> rl RAR ft m Pro act Su ort "r'.171117",
<br /> BILLING INFORMATION:
<br /> In.cele Me ro.poneDtle paxy y be Wiled Wadtlllbna EHO eye ane expended beyond permit payment mvere9e per lank.It
<br /> Aeee s' /��?(i .v 11' Oae / cos Me parry balpnabd halon is dilNnnt Dun he permx yWleenL
<br /> e.g.pmpedy owner,Me pertY meal eckrov4edae Ihic
<br /> Aeeoxeo ra: 18ww66k aeR/ SS fIV nV—bety r"4 Mlln9 hye'9nalure nM des,bekw.
<br /> Dab tervb ciespIaIM MIIMey 6aeaw0aa /� p/E ?� NAME—e.CO-1 GrOUO-Andrew CAecia Tm.E P[OJCCC support papNEpC94JJ 971.761(E.I,LI}
<br /> F«AlenRlt - 52IAwpbml pals YA32ao Ihgnear. / ADOREss 9595 Lucas Ranch Rd. ii Rancho Cucaalon a CA 91730
<br /> Peymanl Type iewska/ DRNka S2l16 .y. SIGNATURE TE ILI Li(zo 19
<br /> EHO--are M Nxiel swan MI
<br /> sev18ED I1mTaWp
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