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SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Glenn Owens 909-581-2922 <br />A <br />C <br />Facility Name Pilot -Flying J #617 <br />Phone # 209-339-4066 <br />I <br />L <br />Address 15100 N. Thornton Road Lodi, CA 95242 <br />I <br />Cross Street Thornton and Highway 12 <br />T <br />Y <br />Owner/Operator Pilot Travel Centers LLC <br />Phone # 864-474-2421 <br />C <br />Contractor Name Jones Covey Group, Inc. <br />Phone # 909-972-7581 <br />TContractor <br />Address 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 <br />CA Lic # 804431 Class A, B, HAZ <br />A <br />Insurer IOA Insurance Services <br />Work Comp # WC2888057 <br />T <br />ICC Technician's Name Josh Estep <br />Expiration Date 5/22/2011 <br />R <br />ICC Installer's Name Josh Estep <br />Expiration Date 10/5/2011 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Installed <br />T <br />21 Main, 21 Sat tom boot <br />20,000 <br />Diesel <br />2001 Double Wall <br />A <br />N <br />Secondary Trans. 92428. Tom boat #28, Secondary 920-21. <br />20,000 <br />Diesel <br />2001 Double Wall <br />K <br />Secondary#1,2,3 to transition #1.Testboot # 3.Tk#3dam. test boot <br />20,000 <br />Diesel <br />2001 Double Wall <br />UDC #13,14/15 & 16/17.Secondary #15-16. Test boot#16. <br />20,000 <br />Regular <br />2001 Double Wall <br />Secondary #12-13, test boot on 913, fillbudcet <br />12,000 <br />Premium <br />2001 Double Wall <br />P <br />Approved p�Conditi��oni�-', Disapproved <br />L <br />A <br />N <br />6(e <br />_ <br />Plan Reviewers NameAM 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 o Title Environmental Compliance Date 12/15/2010 <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 # 909-972-7581 <br />ADDRESS 95995'lLucas <br />tRanch •Road #100 Rancho Cucamonga, CA 91730 <br />SIGNATURE �"'b'� _ " d DATE 12/22/2010 <br />EH230038 (revised 07/22/10) <br />