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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY , - ' ` <br /> 1868 E . Hazelton Ave . , Stockton , Californla '�9520&1 <br /> Telephone : (209 ) 468 -3420 Fax : (209 ) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERII �� P t45 key ; ' ` '` ` ` ' � ` i i <br /> VI <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW: ' <br /> ❑ TANK RETROFIT XPIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 909-232-2997 <br /> Facility Name Pilot Travel Centers LLC Phone # 800-562-6210 <br /> I <br /> L Address 345 Roth Rd , Lathrop , CA 95330 <br /> Cross Street <br /> T <br /> Y Owner/Operator Pilot Travel Centers LLC Phone # 800-562-6210 <br /> C Contractor Name Jones Covey Group , Inc . Phone # 909-972-7581 <br /> 0 <br /> N Contractor Address 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 CA Lic # 804431 Class A, B HAZ <br /> T <br /> R <br /> A Insurer Everest National Insurance Company Work Comp # CAI 002046161 <br /> C <br /> T ICC Technician 's Name Roberto Plaza Expiration Date 09/28/21 <br /> o <br /> R ICC Installer's Name Roberto Plaza Expiration Date 09/28/21 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T T2 (91 ) STP Sump 91000 Premium Unleaded Gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved ivy Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> Nr <br /> Plan Reviewers Name �/ � Date ( 0 l e zo lzx <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 Signature Title Project Manager Date 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 Andrew Garcia TITLE Project Support PHONE # 909-232-2997 <br /> ADDRESS 9595 Lucas Ranch Road # 100 Rancho Cucamonga CA 91730 <br /> SIGNATURE DATE 10/ 13/20 <br /> EH230038 (revised 7-26-2016) 2 <br />