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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 a PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Rob SUIS ( 714 ) 9754257 <br /> APhone # 209 839 - 2000 <br /> C Facility Name FedEx Ground - Trac ( ) <br /> � Address 5655 Hood Way , Tracy CA 95377 <br /> I Cross Street <br /> T <br /> Y Owner/Operator FedEx Ground Phone # 925 - 628 - 5634 <br /> o Contractor Name Jones Covey Group , Inc . Phone # 714 - 975 -4257 <br /> N Contractor Address 9595 Lucas Ranch Rd . , Rancho Cucamonga, CA 91730 CA Lic # 804431 Class A , B , C10 , HAZ <br /> T <br /> R Insurer Starstone National Insurance Company Work Comp # T10231330 <br /> A <br /> T ICC Technician ' s Name Art Perez Expiration Date 8709496 <br /> T <br /> R ICC Installer' s Name Art Perez Expiration Date 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 T3 - Biodiesel Tank - Fill 20 , 000 <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date 2L 2 + J <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." D�A <br /> Applicant's Signature '0 fs' t vim./ Title Jones Covey Group Permitting Date 8/4/2023 <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 ' \� " ' s ' 16 DATE 8/4/2023 <br /> 2of6 <br />