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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 /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <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 EPA Site # Project Contact & Telephone # 909-730 -9185 <br /> A Facility Name Pilot Travel Centers LLC Phone # 800 -562- 6210 <br /> 1 Address 15237 Thornton Rd , Lodi , CA 95242 <br /> L <br /> I 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 # CA1002046161 <br /> c <br /> T ICC Technician ' s Name Expiration Date <br /> 0 <br /> R ICC Installer' s Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> T4 ( 87 Fill Sump) 20 , 000 Unleaded Gasoline <br /> A T5 (91 Fill sump) 12 000 Premium Unleaded Gasoline <br /> N <br /> K <br /> P ❑ Approve pproved with conditions ❑ Disapproved <br /> L e ,4ttach nt With Conditions ) <br /> N LX ( 22I2 � <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WI AN 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 aov4ew 0/"v" a" Title Project Support Date 05/26/2021 <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 # <br /> 888-972 -7581 <br /> ADDRESS 9595 Lucas Ranch Road # 100 Rancho Cucamonga CA 91730 <br /> SIGNATURE anAew 6 "" "" " DATE 05-26- 2021 <br /> EH230038 (revised 7-26-2016 ) 2 <br />