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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECTIVED <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 OCT 4. 6 [017 <br />APPLICATION FOR UNDERGROUND STORAGtNMENTAL HEALTH <br />RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT XPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />909-730-9185 <br />A <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 />TCross <br />Street W. Colony Rd. <br />Y <br />Owner/Operator Pilot Travel Centers LLC <br />Phone # 800-562-6210 <br />C <br />Contractor Name Jones Covey Group, Inc. <br />Phone # 909-972-7581 <br />0 <br />N <br />T <br />Contractor Address 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 <br />CA Lic # 804431 Class A, B HAZ <br />R <br />Insurer Everest National Insurance Company <br />Work Comp # CA1002046171 <br />A <br />C <br />r <br />ICC Technician's Name Issac Garcia <br />Expiration Date 01/14/2019 <br />R <br />ICC Installer's Name Issac Garcia ICC# 8192172 Veeder Root# 842806 <br />Expiration Date 01/14/2019 <br />Tank system work area <br />UDC 1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, etc.) <br />T <br />T1, T2, T3, T4, T5, T6 <br />20k,20k,20k,12k,12k,12k <br />Diesel, Diesel, Diesel, 87, 91, Auto Diesel <br />A <br />UDC's: 19,20,21,22,23,24,25,26,27,28,29,30, i <br />ind 30 satellite. <br />N <br />K <br />P <br />L <br />❑ Approved Approved with conditions <br />Attachment With Conditions) <br />❑ Disapproved <br />A <br />(See <br />N <br />Plan Reviewers Name i "' A Date <br />10/ % � 1:201 -7 1141i <br />'LICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />kQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />: 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 />RKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />\T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />CALIFORNIA." <br />Title Project <br />BILLING INFORMATION: <br />10-16-2017 <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 Rob Sills TITLE Project Support <br />HONE # 714-975-4257 <br />ADDRESS 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 <br />SIGNATURE -DATE DATE 10-16-2017 <br />EH230038 (revised 7-26-2016) 2 <br />