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I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 N 2 9 2019 <br /> Telephone : (209 ) 468 -3420 Fax : (209 ) 468 - 3433 <br /> 171r -r:);-.1r�7?1 � <br /> APPLICATION FOR UNDERGROUND STORAGE TANK 1�,1 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT XPIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Rob Sills 714 - 975 - 4257 <br /> AFacility Name Pilot Travel Centers LLC Phone # 800 -562-6210 <br /> C <br /> I Address 1501 N . Jack Tone Road Ripon , CA 95366 <br /> L <br /> TCross Street W. Colony Rd . <br /> Y Owner/Operator Pilot Travel Centers LLC Phone # 800 -562- 6210 <br /> C Contractor Name Jones Covey Group, Inc . Phone # 909 - 972 - 7581 <br /> 0 <br /> N Contractor Address 9595 Lucas Ranch Road #1100 Rancho Cucamonga , CA 91730 CA Lic # 804431 Class A , B HAZ <br /> T <br /> R <br /> A Insurer Everest National Insurance Company Work comp # CA1002046181 <br /> o <br /> T ICC Technician 's Name Arturo Perez ICC# 8709496 , OPW and EMCO attached Expiration Date 12/20/2020 <br /> o <br /> R ICC Installer's Name Robert Bramhail ICC# 8206958 , OPW and EMCO attached Expiration Date 07/22/2019 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDC 1120 etc.) Installed <br /> T Tank 1 Diesel 20 , 000 Gallons Diesel <br /> A Tank 4 87 12 ,000 Gallons 87 <br /> N <br /> K Tank 5 91 12 , 000 Gallons 91 <br /> Tank 6 Auto - Diesel 12 , 000 Gallons Diesel <br /> Tank 8 Biodiesel 20 , 000 Gallons Biodiesel <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name I I� l «/l (moi 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 /> Applicant's Signature2 " <br /> Title Project support Date 01 -22 - 2019 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank . If <br /> the party designated below is different than the permit applicant, e . g . property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Rob Sills TITLE Project Support PHONE # 714- 975-4257 <br /> ADDRESS 9595 Lucas Ranch Road # 100 Rancho Cucamonga , CA 91730 <br /> SIGNATURE__` ' _ ) �/� DATE 01 - 22 - 2019 <br /> EH230038 (revised 7-26-2016 ) 2 <br />