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0 4 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <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 A UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name Pilot-Flying J#617 Phone# 209-339-4066 <br /> 1 Address 1523 N.Thornton Road <br /> L <br /> I Cross Street Thornton and Highway 12 <br /> T <br /> Y Owner/Operator Pilot Travel Centers LLC Phone# 865-474-2421 <br /> C Contractor Name Jones Covey Group, Inc. Phone# 888-972-7581 <br /> N <br /> r Contractor Address 9595 Lucas Ranch Road#100 CA Lic# 804431 Class A,B,HAZ <br /> R <br /> A insurer IOA Insurance Services Work Comp# WC2888057 <br /> T ICC Technician's Name Robert Vargas 5253061-LIT Expiration Date 6/12/2011 <br /> R ICC Installer's Name Robert Vargas 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 20,000 Diesel 2001 Double Wall <br /> A 20,000 Diesel 2001 Double Wall <br /> N <br /> K 20,000 Diesel 2001 Double Wall <br /> 20,000 Regular 2001 Double Wall <br /> 12,000 Premium 2001 Double Wall <br /> P Approved Approved with conditions Disapproved <br /> L e Attachment With Condition <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 <br /> TO 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 �T t �v v A`" Title Environmental Compliance Date 5/6/2011 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME Holly Mendez TITLE Environmental Compliance PHONE#888-972-7581 xt.205 <br /> ADDRESS 9595 Lucas Ranch Road#100 Rancho Cucamonga, CA 91730 <br /> SIGNATURE � -0-jDATE 5/6/2011 <br /> EH230038(revised 07/22/10) <br /> 2 <br />