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SANJOAQUIN Environmental Health Department <br /> -- - COUNTY - - - <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 ❑ PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Maggie Davis ( 951 ) 463 - 2800 <br /> A <br /> C Facility Name Pilot Travel Centers LLC Phone # (800 ) 562 - 6210 <br /> � Address 345 Roth Rd . , Lathrop , CA 95330 <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 /> N Contractor Address 9595 Lucas Ranch Rd . , Rancho Cucamon aCA 91730 CA Lic # 804431 Class A B HAZ <br /> g , <br /> T > <br /> A Insurer Starstone National Insurance Company Work Comp # T10211051 <br /> T ICC Technician ' s Name Justin Zorn Expiration Date 08/20/23 <br /> R <br /> ICC Installer's Name Justin Zorn Expiration Date 08/20/23 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T Tank 1 87 9 , 000 Gal Regular Unleaded Gas <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date <br /> + � <br /> APPLICANT MUST PERFORM ALL WORK IN ACCO NCE 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 /> Margaret Davis =" ' " <br /> Applicant's Signature omvq�l Title Date <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank . If the party designated below is different than the permit applicant , e . g , property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Maggie Davis TITLE Admin . Assistant PHONE # ( 951 ) 463 - 2800 <br /> ADDRESS 9595 Lucas Ranch Rd . , Rancho Cucamonga , CA 91730 <br /> Margaret Davis <br /> SIGNATURE DATE 08/27/21 <br /> 2 of 6 <br />