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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 /> D TANK RETROFIT ) PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT O COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 909-730-9185 <br /> AFacility Name Pilot Travel Centers LLCPhone # 800-562-6210 <br /> C <br /> I Address 15100 Thorton Road Lodi , CA 95242 <br /> L <br /> TCross Street <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 Contractor Address 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 CA Lic # 804431 Class A , B HAZ <br /> T <br /> R Insurer Everest National Insurance Company Work Comp # CA1002046161 <br /> A <br /> C ICC Technician's Name Roberto Plaza Expiration Date 9/28/2021 <br /> T <br /> R ICC Installer's Name Roberto Plaza Expiration Date 8/28/2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> T T1 (87 Fill sump) 20 , 000 Premium Unleaded Gasoline <br /> N T21 T31 T4 , (87 Fill/STP sump) 20 , 000 Premium Unleaded Gasoline <br /> K T5 87 Fill/STP Sum 20 , 000 <br /> UDC 7-8 <br /> UDC 13 <br /> UDC 16- 17 <br /> P Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions ) <br /> oLo <br /> N Plan Reviewers Name cu� a (I l 0 <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: '1 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: '1 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 /> pplicant's Signature Tille Project Support DateI2'`' 464 I I Z~er I <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 Andrew Garcia TITLE Project Support PHONE # 888-972-7581 <br /> ADDRESS 9595 Lucas R n h Road 9100Rancho Cuc m n a CA 91730 <br /> G! <br /> SIGNATURE DATE 1 Z t zd <br /> EH23003B (revised 7-26-2016 ) 2 <br />