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SAN -JOAQUIN 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# 209-559-4141 <br /> 1 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 <br /> T Contractor Address 9595 Lucas Ranch Rd.,Rancho Cucamonga,CA 91730 CA Lic# 804431 Class A, B, Haz <br /> A Insurer Starstone National Insurance Company work Comp#T1 0211051 <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 I <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 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�ywamund"o: <br /> Margaret Davis.-,--.—.,` �� 10/08/21 <br /> = Administrative Assistant Dat <br /> Applicant's Signature TitleAdministrative <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 <br /> ON: <br /> C212Con mums@,CNAiarg y.com, 'Jones Covey Group,lnc.', <br /> OU=Fuel Construction,CN=Margaret Davls 10/08/21 <br /> SIGNATURE Date:2021.10.2013;48:59-oroo' DATE <br /> 2of6 <br />