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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 /> D TANK RETROFIT )$( PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 909-730-9185 <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 /> Cross Street <br /> T <br /> Y Owner/Operator Pilot Travel Centers LLC Phone # 800-562-6210 <br /> C Contractor Name Jones Covey Group, Inc. Phone # 909-972-7581 <br /> O <br /> N Contractor Address 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 <br /> T CA LIc # 804431 Class A B HAZ <br /> R <br /> A Insurer Everest National Insurance Company Work Comp # CA1002046161 <br /> C <br /> T ICC Technician's Name Roberto Plaza ICC # 8036194 Expiration Date 09 / 28 / 2021 <br /> R ICC Installer's Name Roberto Plaza ICC # 8036194 Expiration Date 09 / 28 / 2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1/2, ero.) Installed <br /> T UDC 24 Sat Gasoline <br /> A UDC 13 Diesel <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions E 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 <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 /> pplicanCsSignature Title Project Support Date :i; az 61 to t <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 PHONE # (f8 $ 33J7) 71; Y1 C ,.t . 773 <br /> ADDRESS 9595 Lucas Ranch Rd . # 100 , Rancho Cucamonga , CA 91730 <br /> SIGNATURE DATE I ZI 2 6 f zo + 9 <br /> i <br /> f <br />