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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />ztej a III Wei <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 <br />EPA Site# <br />Project Contact& Telephone #Glenn Owens 888-972-7581 <br />� <br />Facility Name Pilot Flying J #617 <br />Phone# 209-339-4066 <br />1 <br />L <br />Address 15100 N. Thornton Rd., Lodi, CA 95242 <br />I <br />T <br />Cross Street Hwy 12 <br />Y <br />Owner/Operator pilot Travel Centers <br />Phone# 864-474-2421 <br />C <br />Contractor Name Jones Covey Group, Inc.Phone <br /># 888-972-7581 <br />Q <br />N <br />Contractor Address 9595 Lucas Ranch Rd.4100, Rancho Cucamonga <br />CALic# 804431 Class A, B, Haz <br />T <br />A <br />Insurer Granite State Insurance Co. <br />Work Comp# WC009970790 <br />T <br />T <br />ICC Technician's Name Steve Sills <br />Expiration Date 3-29-15 <br />R <br />ICC Installer's Name Anthony Aguilar <br />Expiration Date 8-20-15 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />20,000 <br />Diesel <br />2001 Dbl Wall <br />A <br />20 000 <br />Diesel <br />2001 Dbl Wall <br />N <br />K <br />20 000 <br />Diesel <br />2001 Dbl Wall <br />20, 000 <br />2001 Dbl Wall <br />12, 000 <br />Premium <br />2001 Dbl Wall <br />P <br />C Approved Approved with conditions C Disapproved <br />Le <br />Attachment With Conditions) <br />l <br />N <br />Plan Reviewers Name Date <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: "I 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 />Applicant's SignatureTitle Construction Manager Date 1/15/14 <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 Glenn Owens <br />Lucas Ranch Rd. <br />MICR/1 <br />EH230038 (revised 10/30/12) <br />Construction Manager PHONE# 888-972-7581 <br />2 <br />., CA 91730 <br />TE 1/15/14 <br />