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• 0 <br /> SA N:10 A Q U I N Environmental Health Department <br /> COUNTY <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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Issac Gracia 909-239-1137 <br /> C Facility Name Pilot Travel Centers LLC Phone# 800-562-6210 <br /> I <br /> L Address 1501 N. Jack Tone Rd Ripon, CA 95366 <br /> TCross Street W. Colony Rd <br /> Y Owner/Operator Pilot Travel Centers LLC Phone# 800-562-6210 <br /> C Contractor Name Jones Covey Group Inc Phone# 888-972-7581 <br /> 0 <br /> N Contractor Address 9595 Lucas Ranch Rd Suite 100 <br /> T CA Lic# 804431 Class A, B Haz <br /> A Insurer Everest National Insurance Company Work Comp# CA1002046181 <br /> C <br /> T ICC Technician's Name Issac Gracia ICC#8192172 Expiration Date 01/14/2019 <br /> 0 <br /> R ICC Installer's Name Issac Gracia ICC#8192172 Expiration Date 01/30/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T UDC's 1-2,3-4,5-6,7-8,9-10,11-12, 13, 14-15 and 16 N/A N/A N/A <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name :Qm/p Mo_m—j� Date C;)� 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 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: "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." _ <br /> ��— <br /> Applicant's Signature Title <br /> Project Manager Date 5/29/2018 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Issac Gracia TITLE Project Manager PHONE#888-972-7581 <br /> ADDRESS 9595 Lucas Ranch Rd Suite 100, Rancho Cucamonga CA, 91730 <br /> SIGNATURE �' DATE 05/29/2018 <br /> 2of6 <br />