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w <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ®UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Adarn Markos <br /> C Facility Name Pilot Flying J#618 Phone# 888 972-7581 <br /> 1 Address 1501 N.Jack Tone Rd. Ripon,CA 95366 <br /> L <br /> I Cross Street Hwy 99 <br /> T <br /> Y Owner/Operator Phone# <br /> o Contractor Name Jones Covey Group, Inc. Phone# (888)972-7581 <br /> N Contractor Address 9595 Lucas Ranch Road#100 CA Lic# 804431 Class A,B NAZ <br /> T <br /> R insurer IOA Insurance Services-ORG Work Comp# CA10002046141 <br /> A <br /> C <br /> T ICC Technician's Name See Attached Expiration Date <br /> R ICC Installer's Name See Attached Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump.91 leak detector.UDC 112,etc.) Installed <br /> T Dispenser 25Fz <br /> � " <br /> A 3 <br /> N <br /> K <br /> P E Approved Approved with conditions E Disapproved <br /> L (See A tachment With Conditions) <br /> A <br /> N Mao= <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 AGENTS 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." CONTRACTORS 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 Signature rmlts Date 1/7/15 <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 Adam Markos TITLE Permitting PHONE# (888)972-7581 <br /> ADDRESS 9595 Luca Ranch Rd.#100,Rancho Cucamonga,CA 91730 <br /> SIGNATURE DATE 1/7/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />