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y <br /> ENVIRONANTAL HEALTH DPPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 RECEIVED <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> JAN 2015 <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 ®UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Adam Markos <br /> A Phone# <br /> (888) 972-7581c FacilityName pilot Flying J #618 <br /> 1 Address 1501 N.Jack Tone Rd., Ripon, CA 95366 <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 <br /> T AB HAZ <br /> R <br /> A Insurer IOA Insurance Services-ORG Work Comp# CA10002046141 <br /> T <br /> T ICC Technician's Name See Attached Expiration Date <br /> O ICC Installer's Name See Attached pi <br /> R Expiration Date <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 Dispenser 25 <br /> A <br /> N <br /> K <br /> P E Approved C Approved with conditions E Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N 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 F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Permits 12/23/14 <br /> Applicant's Signatur - i e Date <br /> BILLING INFORMATION <br /> Indicate the responsible party to be billed for additional EHD staff time I 'ONES COVEY'GROUP,INC. <br /> the party designated below is different than the permit applicant, e <br /> responsibility for the billing by signature and date below. CD <br /> CONSTRUCTORS <br /> NAME <br /> NAME TITLE <br /> ADDRESS Adam Markos 9595 Lucas Ranch Rd.#100 <br /> amarkos@jonescovey-com Rancho Cucamonga,CA 91730 <br /> SIGNATURE 888.972.7581 <br /> 909.484.0300 Fax <br /> EH230038(revised 07-17-2014) <br /> California State Contractors License#804431 A,0 Haz <br /> 2 <br />