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Oct. 10. 2014 1 :55PM No, 8386 P. 1 <br /> ENVIRONWENTAL HEALTH Dlok'- RTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, Callfomia 95205RECEIVED <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> OCT 10 2014 <br /> Y) APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW- DEPARTMENT <br /> OTANK RETROFIT OPIPIMGREPAIRIRETROFIT OUDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Phone# (209)599-4141 <br /> C Facillty Name Pilot Flying J -#618 Ripon <br /> I — <br /> L Address 1501 N.Jack Tone Road, Ripon,CA 95366 <br /> 1 Gross Street Highway 99 <br /> T <br /> Y Owned0perator Pilot Flying JLLC Phone# (800)562-6210 <br /> 0 <br /> 0- Contractor Name tones Covey Group, Inc. Phone# (888)972-7581 <br /> T <br /> IN ---TCA Lic# 804431 <br /> Contractor Address 9595 Lucas Ranch Road#100 Class A,B HAZ <br /> R <br /> A Insurer 10A Insurance Services-ORG Work Camp# CA10002046141 <br /> C <br /> T ICC Technician's Name See Attached Expiration Date <br /> Expiration Date <br /> ICC Installer's Name See Attached <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (La,87 piqAngsump.91 leak dete=r,UDC 112,t�W.) Installed <br /> T Dispenser#22 LJDC Diesel <br /> A <br /> N —----- <br /> K <br /> P E: Approved F Approved with conditions E Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> I <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOFtWHICH THIS PERMIT IS ISSUED,f SHALL NOT EMPLOY ANY PERSON INSUCH:A MANNER AS TO BECOME SUBJECT TO <br /> WORKEITS COMPENSATION LAWS OF CALIFORNIA." CONTRACTORS 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> lApplicance Slqnawre- Tide Permits Dale <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 /> responsibill for the bilin9blsigna ure anddatebelow. <br /> T <br /> NAME ITL PHONE <br /> % C()CaM,0 <br /> ADDRESS 6 A <br /> SIGNATURE DATE <br /> rzH230038(ravliwl 07-172014) <br /> 2 <br />