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-0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RE CEIVE <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 OCT 116 Z017 <br /> APPLICATION FOR UNDERGROUND STORAGtNMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT XPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 909-730-9185 <br /> � <br /> Facility Name Pilot Travel Centers LLC Phone# 800-562-6210 <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 <br /> r Contractor Address 9595 Lucas Ranch Road#100 Rancho Cucamonga,CA 91730 CA Lic# 804431 Class A, B HAZ <br /> R <br /> A Insurer Everest National Insurance Company Work Comp# CA1002046171 <br /> T ICC Technician's Name Issac Garcia Expiration Date 01/14/2019 <br /> R ICC Installer's Name Issac Garcia ICC#8192172 Veeder Root#B42806 Expiration Date 01/14/2019 <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 T1, T2, T3, T4, T5, T6 20k,20k,20k,12k,12k,12k Diesel, Diesel, Diesel, 87, 91,Auto Diesel <br /> A UDC's: 19,20,21,22,23,24,25,26,27,28,29,30,i ind 30 satellite. <br /> N <br /> K <br /> P ❑ Approved XApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N �-" Date 1 Lf (� / C� U <br /> Plan Reviewers Name <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 � �-�c� Title Project support Date 10-16-2017 <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 10-16-2017 <br /> EH230038(revised 7-26-2016) 2 <br />