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7 Wx:.va,--- ---- ------ ,*** <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 RECEIVED <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 JUN 16 2014 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTALHEALTIH <br /> PERMIT/SERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW, <br /> 0 TANK RETROFIT n PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Glenn Owens 888-972-7581 <br /> A --Tphone# 209-599-4141 <br /> C FacilityName Pilot Flying J #618 <br /> 1 <br /> L Address 1501 Jack Tone Road, . Ripon, CA 95326 <br /> T I Cross Street S CA-99 <br /> Y Owner/Operator Pilot Travel Centers Phone# 864-474-2421 <br /> 0 C Contractor Name Jones Covey Group, Inc Phone# 888-972-7581 <br /> N Contractor Address 9595 Lucas Ranch Rd. #100 CA Lic# 804431 Class A, B, Haz <br /> T <br /> R <br /> A Insurer Granite State Insurance Co. WorkComp# WC009970790 <br /> C <br /> T ICC Technician's Name Steve Sills Expiration Date 3-29-15 <br /> 0 <br /> R ICC Installer's Name Anthony Aguilar Expiration Date 8-20-15 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le.87 piping sump,91 leandeleclor,UDC 112,etc.) Installed <br /> T 20, 000 Diesel 1995 Dbl Wall <br /> A 20, 000 Diesel 1995 Dbl Wall <br /> N <br /> K 20, 000 Diesel 1995 Dbl Wall <br /> 20,000 Bio-Diesel 2014 .Dbl Wall <br /> P El Approved h/Approved with conditions El Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> /)V <br /> ) I <br /> N Plan Reviewers Nam 1A - Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR ANCE 4 JOAQUIN COUNTY O�RDI ANCES,STATE LAWS, REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT. A�JER OR LICENSED AGE SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT r 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> ,Applicant's Signature Construction Manager Date <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 Glenn Owens TITLE Construction Manager PHONE# 888-972-7581 <br /> ADDRESs 9595 Lucas Randa Rd. .Ste 100, Rancho Cucamonga, CA 91730 <br /> SIGNATURE DATE-5/21/14 <br /> EH230038(revised 110130/12) <br />