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-- -SANJOAQU W -COU N.T-Y-.-.- <br />.11=12 r W It A 0+ IA <br />— <br />aze on W., UU on, Calnumia 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 (7 <br />C <br />APPLICATION FOR UNDERGROUND STORAGE TANK DEC 0 7 2016 <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE RED % I I , r <br />Wa, /I HEALTH <br />0 TANK RETROFIT )(PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT I] COLD ST <br />F <br />A <br />EPA Site # <br />IrMPNT <br />Project Contact& Telephone 4 909-730-9185 <br />C <br />Facility Name Pilot Travel Centers LLC <br />Phone# 800-562-6210 <br />1 <br />L <br />Address 1501 N. Jack Tone Road Ripon, CA 95366 <br />T 1 <br />Cross Street <br />Y <br />Owner/Operator Pilot Travel Centers LLC <br />Phone # 800-562-6210 <br />C <br />0 <br />Contractor Name Jones Covey Group, Inc. <br />Phone # 909-972-7581 <br />N <br />T <br />_Contractor Address 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 CALlc# 804431 Class A, B HAZ <br />R <br />A <br />Insurer Everest National Insurance Company <br />Work Comp # CA1 002046161 <br />0 <br />T <br />- <br />ICC Technician's Name Steve Sills <br />— <br />Expiration Date 4/14/17 <br />0 <br />R <br />ICC Installers Name Steve Sills <br />Expiration Date 4/14/17 <br />Tank system work area <br />o.e. 87 plOng sump. 91 leak detester, UDC V2, OW.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />T5 (91 STP sump) <br />12,000 <br />Premium Unleaded Gasoline <br />A <br />N <br />T6 (Auto Diese STP sump) <br />12,000 <br />Auto Diesel <br />K <br />—Approved <br />P <br />❑ Approved With conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name Date— <br />V <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: -1 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 TIJE)WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA <br />Applicant's Signature —c n,re ProjectMana erDace 12-7-16 <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 />NAME- Steve Sills TITLE Project Manager —PHONE# 909-730-9185 <br />12-7-16 <br />EH230038 (revised 7-26-2016y- 2 <br />