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SA N JOAQUIN Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE . DO NOT WRITE IN ANY SHADED AREAS , <br /> INDICATE PERMIT TYPE : <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # CAL00D354766 PROJECT CONTACT ROBERT SILLS PHONE# 714-975 -4257 <br /> FACILITY NAME PILOT TRAVEL CENTERS LLC PHONE # 800 - 562 - 6210 <br /> ADDRESS 1501 N . JACK TONE RD . RIPON CA 95366 <br /> CROSS STREET W. COLONY RD . <br /> OWNER OPERATOR PILOT TRAVEL CENTERS LLC . PHONE # 800 - 562 - 6210 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME JONES COVEY GROUP INC . FPHONE # 888 - 972 -7581 <br /> CONTRACTOR ADDRESS 9595 LUCAS RANCH RD. #100 RANCHO CUCAMONGA CA 91730 cA LIC # 804431 CLASS A, B, HAZ <br /> INSURER EVEREST NATIONAL INSURANCE COMPANY WORKER COMP# CA10002046191 <br /> FIRE DISTRICT RIPON FIRE DISTRICT PERMIT # N/A - PER DFM DENNIS BITTERS 209 - 599-4209 <br /> LABORATORY NAME ALPHA ANALYTICAL INC COUNTY SACRAMENTO PHONE # (916) 366 - 9089 <br /> SAMPLING FIRM BROADBENT & ASSOCIATES INC. PHONE # 530- 5664400 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39 - 7 1, 000 GALLONS OIL ( FROM OIL WATER SEPARATOR) N/A <br /> 39 - <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS , AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSAT N LAWS OF CALIFORNIA." n <br /> APPLICANT'S SIGNATURE TITLE :: S �rn��- `tom lA MATE <br /> ❑ APPROVED A APPROVED WITH CONDITION (S ) ❑ DISAPPROVED <br /> (SE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME ' DATE.aZ ;tL& Kj <br /> ANY DEVIATIONS FRO THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> CONDITIONS : <br /> 3of10 <br />