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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 # Bruno Espinoza ( 909 ) 543 - 8904 <br /> � <br /> Facility Name Pilot Flying J 617 Phone # ( 209 ) 3394066 <br /> I <br /> L Address 15237 N . Thornton Road , Lodi CA 95242 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Pilot Travel Centers LLC Phone # ( 209 ) 339 -4066 <br /> o Contractor Name Jones Covey Group , INC . Phone # ( 909 ) 972 - 7581 <br /> N Contractor Address 8595 Lucas Ranch Rd . , Rancho Cucamonga, CA 91730 CA Lic # 804431 Class A B , HAZ <br /> A Insurer Berkshire Hathaway Homestate Insurance Company Work Comp # JOWC320551 <br /> T ICC Technician ' s Name Expiration Date <br /> T Isaac Garcia p ' 8192172 <br /> R ICC Installer' s Name Isaac Garcia Expiration Date 8192172 <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 STP SUMP <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 1Q 04 <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." <br /> 9/20/2022 <br /> Applicant's signature Title Jones Covey Group - Permitting Date <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 Bruno Espinoza TITLE Jones Covey Group - Permitting PHONE # 909 - 543 - 8904 <br /> ADDRESS 9595 Lucas Ranch Rd . , Rancho Cucamonga , CA 91730 <br /> SIGNATURE = =r DATE 9/20/2022 <br /> 2of6 <br />