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SA N JOAQUIN Environmental Health Department <br /> Pf <br /> COUNTY . V: "1 „•aa <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEC 16 2022 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> ENVIRONMENTAL HEALTH <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/EMANIT2ANER VICES <br /> F EPA Site # Project Contact & Telephone # Rob Sills ( 714 ) 975 -4257 <br /> C Facility Name Pilot Flying J 618 Phone # ( 209 ) 339 - 4066 <br /> L Address 1501 N Jack Tone Rd . , Ripon CA 95366 <br /> 1 Cross Street <br /> T <br /> Y Owner/operator Pilot Travel Centers LLC Phone # ( 209 ) 339 -4066 <br /> o Contractor Name Jones Covey Group , Inc . Phone # ( 909 ) 972 - 7581 <br /> N Contractor Address CA Lic # Class <br /> T 9595 Lucas Ranch Rd . , Rancho Cucamonga, CA 91730 804431 A , B , C10 , HAZ <br /> A Insurer Berkshire Hat Homestate Insurance Com an Work Comp # JOWC320551 <br /> T ICC Technician ' s Name Issac Garcia Expiration Date 8192172 <br /> R ICC Installer's Name Issac Garcia Expiration Date 8192172 <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 Diesel Dispenser #26 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A i <br /> N Plan Reviewers Name Date x 1 2 2 .`73 <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." l0 poD �f' DD <br /> Applicant's Signature ' oi 1 VVy Title Jones Covey Group Permitting Date 12/ 15/2022 <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 Robert Sills TITLE Jones Covey Group - Permitting PHONE # 714 - 975 -4257 <br /> ADDRESS 9595 Lucas Ranch Rd . # 100 , Rancho Cucamonga CA 91730 <br /> SIGNATURE ` \10 �2 (iC/.l' DATE 12/8/2022 <br /> 2 of 6 <br />