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RECEIVED <br /> S A N JOAQUIN Environmental H@56 Oq$a gnt <br /> COUNTY <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Bruno Espinoza (909) 543-8904 <br /> A <br /> C Facility Name Pilot Flying J 617 Phone# (209) 339-4066 <br /> I Address 15237 N. Thornton Road, Lodi CA 95242 <br /> I 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 /> T Contractor Address 9595 Lucas Ranch Rd., Rancho Cucamonga,CA 91730 CA Lic# $04431 Class A, B, HAZ <br /> A Insurer Berkshire Hathaway Homestate Insurance Company Work Comp#JOWC320551 <br /> T ICC Technician's Name <br /> T Art Perez Expiration Date 8709496 <br /> R ICC Installer's Name Expiration Date <br /> R Art Perez p' 8709496 <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 UDC #1/2 & 5/6 <br /> A <br /> N <br /> K <br /> P ❑ Approved X Approved with conditions ❑ Disapproved <br /> L ee Ntachment With Conditions) <br /> A p <br /> N Plan Reviewers Name Date (2 O 12122 <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 /> DQDD Jones Cove Grou -Permittin 12/1/2022 <br /> Applicant's Signature Vey Title y p g 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 Robert Sills TITLE Jones Covey Group-Permitting PHONE# 714-975-4257 <br /> ADDRESS 9595 LUccas Ranch Rd.,//�Rancho Cucamonga, CA 91730 <br /> SIGNATURE `\� �2Cir/.Y DATE 12/11/2022 <br /> 2of6 <br />