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Oct, 10. 2014 2:O/FM No, 838/ F. 1/1 <br /> D <br /> ENVIRONW, -NTAL HEALTH DAkir- 'N11VED <br /> SAN JOAQUIN COUNTY �& <br /> 1868 E. Hazelton Ave., Stockton, Cialifomia 95205 OCT 10 2014 <br /> Telephone: (209)468-3420 Fax, (209)468-3433 <br /> TH <br /> APPLICATION FOR UNDERGROUND STORAGE 7 AtpVIRONIVIENTAL HEAL <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 160 PAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT 0 PIPING REPAIR/RETROFIT O UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Pilot Flying J-#618 Ripon Phone# (209)599-4141 <br /> I Address <br /> L 1501 N.Jack Tone Road, Ripon,CA 95366 <br /> I Cross Street Highway 99 <br /> T <br /> y Owner/Operator Pilot Flying] LLC Phone# (800)562-6210 <br /> 0 Contractor Name Jones Covey Group, Inc. Phone# (888)972 <br /> 0 -7591 <br /> N <br /> T Contractor Address 9595 LUcas Ranch Road#100 CA Lio# 804431 Class A,13 HAZ <br /> R Insurer 10 Work Co <br /> A A Insurance Services-0116 mp# CA10002046141 <br /> G <br /> T ICC Technician's Name See Attached Expiration Date <br /> 0 <br /> R ICC Installers Name See Attached Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i^87 piping sump,91 leak de4ftl0f,UDC 1/2,etc.) Installed <br /> T Dispenser#22 UDC Diesel <br /> A <br /> IN <br /> K <br /> P EApproved Approved with conditions C Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name ef,10, mouk;z 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 FDR'WHICH THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKERS COMPENSATION LAWS OF CALIFORNIA! CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING' 'I CERTIFY <br /> THAT IN THE PERFORMANCE 9F THEE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> jApplicant's Signature 71116 Permits 13919 <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 /> onsibility for the b Ing�signa re <br /> resp 111' b * tu and date below. <br /> /,v_� A I t4b� <br /> NAME 7 <br /> ADDRESS 'A <br /> SIGNATURE DATE <br /> EH230038(ravised 07-17-2014) <br /> 2 <br />