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SAN JOAQUIN <br />C C' I~l i`,i T v <br />Environmental Health Department <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 l& UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Albert Barajas (909) 213-5266 <br />A <br />Facility Name FedEx Ground - Tracy <br />Phone # (888) 972-7581 <br />1 <br />Address 5655 Hood Way, Tracy, CA 95377 <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator FedEx Freight, Inc. <br />Phone # (901) 818-7500 <br />o <br />Contractor Name Jones Covey Group, Inc. <br />Phone # (909) 972-7581 <br />TContractor <br />Address 9595 Lucas Ranch Rd. #100, Rancho Cucamonga, CA 91730 <br />CA Lic # 804431 Class A,B,Haz,C-10 <br />A <br />Insurer Insurance Company of the West <br />Work Comp # WVA506868303 <br />TICC <br />Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Installed <br />T <br />T1 - Diesel STP Sump <br />30,000 <br />A <br />N <br />T2 - Diesel STP Sump <br />30,000 <br />K <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <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 />Assistant Environmental <br />D <br />Applicant's Signature Ct(4tit,, B M- Title Compliance PM Date 07/25/2025 <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 />Assistant Environmental <br />NAME Albert Barajas TITLE Compliance PM PHONE # (909 ) 213-5266 <br />ADDRESS 9595 Lucas Ranch Rd. Rancho Cucamonga, CA 91730 <br />SIGNATURE 6W411rt 3--&1jJ' DATE 07/25/2025 <br />2of6 <br />