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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 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# Glenn Owens 888-972-7581 <br /> A <br /> C Facility Name Pilot Flying J #618 Phone# 209-599-4141 <br /> 1 Address <br /> L 1501 Jack Tone Road, Ripon, CA 95326 <br /> 1 Cross Street S CA-99 <br /> T <br /> Y Owner/Operator Pilot Travel Centers Phone# 864-474-2421 <br /> o Contractor Name Jones Covey Group, Inc . Phone# <br /> 888-972-7581 <br /> N Contractor Address CA Lic# <br /> T 9595 Lucas Ranch Rd. #100 804431 Class A, B, Haz <br /> A Insurer Granite State Insurance Co . Work Comp# WC009970790 <br /> C ICC Technician's Name <br /> T Steve Sills Expiration Date 3-29-15 <br /> R ICC Installer's Name AnthonyAguilar Expiration Date 8-20-15 <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 20, 000 Diesel 1995 Dbl Wall <br /> A <br /> N 20, 000 Diesel 1995 Dbl Wall <br /> K 20, 000 Diesel 1995 Dbl Wall <br /> 12, 000 1995 Dbl Wall <br /> 12, 000 Recrular 1995 Dbl Wall <br /> 12, 000 Premium Plus 1995 Dbl Wall <br /> P C Approved 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 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_. Tltle Construction Manager Date 12/9/13 <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 Ia icas Ranch Rd. , Ste 100, Rancho Cucamonga, CA 91730 <br /> SIGNATURE DATE 12/9/13 <br /> EH230038(revised 10/30/12) <br /> 2 <br />