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0 • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Mp`! 0 9 X018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIROPAA MINT <br /> RETROFIT OR PIPING REPAIR PERMIT ,-A'EA,CTM D <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT XPIPiNG REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> Project Contact&Telephone# Rob Sills 714-975-4257 <br /> F EPA Site# Phone# 800-562-6210 <br /> Facility Name Pilot Travel Centers LLC <br /> Address 1501 N.Jack Tone Road Ripon,CA 95366 <br /> I <br /> I Cross Street W.Colony Rd. <br /> Y Owner/Operator Pilot Travel Centers LLC Phone#$00-562-6210 <br /> I <br /> Phone# 909-972-758 <br /> C <br /> o Contractor Name Jones Covey Group,Inc. <br /> N Contractor Address 9595 Lucas Ranch Road#100 Rancho Cucamonga,CA 91730 CA Lic# 804431 Class A, B HAZ <br /> T Work Comp# CA1002046181 <br /> R Insurer Everest National Insurance Company <br /> A Expiration Date 05/13/2018 <br /> C ICC Technician's Name Rocky Valencia ICC#8257643 Veeder Root#844220 p <br /> T <br /> o ICC Installer's Name James Blaine ICC#8192172 Veeder Root#843163 Expiration Date 07/15/2018 <br /> Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 piping sump,91 leak detector.UDC 112,etc.) <br /> fTank 2 Diesel 20,000Gallons Diesel <br /> T 20,000Gallons Diesel <br /> RFA Tank 3 Diesel <br /> N12,000Gallons Unleaded 87 <br /> K Tank 4 Unleaded 87 <br /> P El Approved <br /> Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N )Date <br /> Plan Reviewers Name <br /> S AND RULES AND <br /> APPLICANT MUST PERFORM ALL WORK IN ACC ANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE <br /> IF,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED GENTS SIGNATURE ERTES THE FOLLOWING: (' <br /> AQUIN I CERTIFY THAT IN <br /> ULATIONS OF SAN <br /> JO <br /> HE PERFORMTO <br /> ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SU"I CETIFY <br /> BJECT <br /> WORKERS THAT IN THSIGNATURE CERTIFIES THE FOLLOWING: <br /> E PERFORMANCE OF THE WORK FOR WHICH THIS ERMIT IS ISSUED.II SHALL HIRING OR MP OY PERSONS SUBJECT TQ WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA. 05_0$-2018 <br /> ,Applicant's Signature <br /> �?t_ ,��- ,��� TitleProject support Date <br /> i <br /> BILLING INFORMATION: <br /> per <br /> If <br /> erage <br /> Indicate the responsible party to be illd or nd hleopermit app/cant,nal ED staffee.g. property owner,the party mustexpended beyond prmit paymentvacknowledgekthis <br /> the party designated below is different <br /> responsibility for the billing by signature and date below. 714-975-4257 <br /> NAME <br /> Rob Sills TITLE Project Support PHONE# <br /> ADDRESS 9595 Lucas Ranch Road#100 Rancho Cucamonga,CA 91730 05-08-2018 <br /> , DATE <br /> SIGNATURE <br /> EH230038(revised 7-26-2016) 2 <br />