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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNT <br /> Y4 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK AUG 2 2 2014 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT 0 COLD STAliTA6WU E- <br /> F EPA Site# Project Contact&Telephone#Glenn Owens 888-972-7581 <br /> A I Phonei 209-599-4141 <br /> c FacilityName pilot Flying J #618 <br /> 1 Address 1501 Jack Tone Road, Ripon., CA 95326 — <br /> L <br /> TCross Street S CA-99 <br /> — <br /> Y Owner/Operator Pilot Travel Centers Phone# 864-474-2421 <br /> 0 C Contractor Name Jones Covey Group, Inc Phone# 888-972-7581 <br /> N Contractor Address 9595 Lucas Ranch Rd. #100j ic# 804431 Class A, B, Haz CAU <br /> R WorkComp# WC009970790 <br /> cInsurer Granite State Insurance Co. <br /> ExpirationDate 3-29-15 <br /> T ICC Technician's Name Steve Sills <br /> 0 <br /> R ICC Installer's Name Anthony A uilar Expiration Date 8-20-15 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (1,e.87 pipingsump,91" InstalledRdelector,UDC 112,etc.) I - <br /> 20, 000 Diesel 1995 Dbl Wall <br /> T <br /> A 20, 000 Diesel 1995 Dbl Wall <br /> N <br /> K 20, 000 Diesel 1.995 Dbl Wall <br /> 20,000 Bio-Diesel 2014 .Dbl Wall <br /> J <br /> P ❑ Approved )�I/Approved with conditions El Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> IN Date 02.1 4n- <br /> Plan Reviewers Name 6-- <br /> APPLICANT MUST PERFORM ALL WORK ACCORJAN4E WIT AN JOAQUIN COUNTY ORD ANCES,STATE LAWS,A D RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT. ER OR JOAQUIN <br /> GE SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> 4 LL N M 0Y Y <br /> NOT <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOTEM OY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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." ction Manager Dal- <br /> jApocant's signaiur <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 /> NAMEGlenn Owens TITLE_Construction manager PHONE# 888-972-7581 <br /> ADDRESS 9595 Lu as Ranch Rd. , Ste 100, Rancho Cucamonga, CA 9.1730 <br /> SIGNATURE DATE 5JZ 14 <br /> EH230038(revised 10/30112) <br />