Laserfiche WebLink
'A N J O A I I I Environmental Health Department <br /> —COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIG PERMIT EXPIRES 180 GAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT D PIPING REPAIPJRETROFIT A UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site Project Contact&Telephone# Albert Bara as 909) 13-5 66 <br /> C Facility Name pilot Flying J 618 Phone# (888) 97 -7581 <br /> � Address 1501 N Jack Tone Rd Ripon CA 95366 <br /> Cross Street <br /> T <br /> y OwnerfOperator pilot Travel CentersLLO Phoneii 4 4 51-6 2 <br /> C Contractor Name Jones Covey Group, Inc, Phone 90 97 -7561 <br /> TContractor Address 9595 Lucas Ranch R%;.N100,Rans+,o Cucamonga,CA 9S7n CA tIC# 304431 Class A,B,Haz,O-1 Q <br /> A Insurer Insurance Company of the Vilest Work Camp# W A50 86830 <br /> TICC Technician's Name Expiration Date <br /> ° ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> CI.e_87 ppuq wmp,9,kah dauxw.UDG 1 Q,e1c.1 Installed <br /> T 8b Diesel Shed Sump <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions El Disapproved <br /> L (See Attachmeni With Condilions) <br /> A <br /> N Plan Reviewers Dame Date <br /> APALICANT MUST PERFORM ALL wpRK IN AIXORDANCE WITH S&N JOAQUIN COUNW ORpIRANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> J0AQLJ1N COUNTY, F ENVIRO MEKTAL HEALTH DEPARTMENT-OWNER OR LICENSED AO.ENT3 SMNATURE CERTIFIES W- FOLLOL4NG: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUaJECT To <br /> WORKERS COMPENSA nohr LAWS OF CALIFORNIA.- CONTRACTOR'S H1R4NG OR SU9CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> YHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THM PERMIT I$ISSUE0,I SHALL EMPLOY PERSONS SUWrCCT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA_' <br /> Assistant Envirenrnenlal <br /> Applicanrs5 naium a&,a- T6a Cam fiance PM D b. <br /> BILLING INFORMATION: <br /> Indlcate the resWsible party to he billed for additlona] EHO 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 reSp onsi billty for the billing by signature and date below_ <br /> Assistant Environmental <br /> 909} 3-56 <br /> NAME Albert Barajas TFFLE CDrrlrrliantt PM PHONE# J <br /> nnORl=ss 9595 Lucas Rand Rd. Rancho Cucamonga, CA 91730 <br /> siGriATuRrt a&-,cr ' �4- bArE 09/041 0 5 <br /> 2of6 <br />