Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> -- COUNTY -- <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 # Maggie Davis 951 - 463 -2800 <br /> C Facility Name Pilot Flying J 618 Phone # 209 - 5594141 <br /> Address 1501 N . Jack Tone Rd . , Ripon , CA 95366 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Pilot Travel Center Phone # 865 - 588 - 7488 <br /> C Contractor Name Jones Covey Group , Inc , Phone # <br /> N Contractor Address 9595 Lucas Ranch Rd . , Rancho Cucamonga, CA 91730 CA Lic # 804431 Class A , B , Haz <br /> T <br /> A Insurer Starstone National Insurance Company Work Comp # T10211051 <br /> T ICC Technician ' s Name Shawn Rodriguez 8412602 Expiration Date 11 / 13/22 <br /> R ICC Installer's Name Shawn Rodriguez 8412602 Expiration Date 04/ 15/23 <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 Tank 4 ( Fill Spill Bucket) 12 , 000 Gal 87 Unleaded <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions ) <br /> A 12,1 NPlan Reviewers Name Date 1 10 <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." w „�v., ", , <br /> Margaret Davis .=..LD Wgtd °� 10/08/21 <br /> a° Administrative Assistant i <br /> ins <br /> Applicant's Signature Title AdmDate <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 <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Maggie Davis TITLE Administrative Assistant PHONE # 951 -463 -2800 <br /> ADDRESS 9595 Lucas Ranch Rd . , Rancho Cucamonga , CA 91730 <br /> Digitally signed by Margaret Davis <br /> Margaret Davis ON: C=11S, E=mdaescovey.com, 'Jones Covey Group,lnc.', <br /> lt <br /> O -Fuel Construction,ion, CN <br /> CN=Margaret Davis 10/08/21 <br /> SIGNATURE Date: 2021 .10.20 13:4e:59-07'00' DATE <br /> 2of6 <br />