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RECEIVE [ <br /> SAN JOAQUIN Environmental H@Eli OZnt <br /> COUNTY <br /> ENVIRONMENTAL HEALTH <br /> P RMIT/ SERVICES <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 /> A <br /> C Facility Name Pilot Flying J 617 Phone # ( 209 ) 339 - 4066 <br /> � 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 CA Lic # Class <br /> T 9595 Lucas Ranch Rd . , Rancho Cucamonga , CA 91730 804431 A , B , HAZ <br /> A Insurer Berkshire Hathaway Homestate Insurance Com an Work Comp # JOWC320551 <br /> T ICC Technician ' s Name <br /> T Art Perez Expiration Date 8709496 <br /> R ICC Installer' s Name Art Perez Expiration Date 8709496 <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 UDC # 1 /2 & 5/6 <br /> A <br /> N <br /> K <br /> P ❑ Approved X Approved with conditions ❑ Disapproved <br /> L A ee tach nt With Conditions ) <br /> A �p <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. " <br /> DQDD Jones Cove Group - Permitting 12/ 1 /2022 <br /> Applicant's Signature '� • Vr/y Title y p g 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 Robert Sills TITLE Jones Covey Group - Permitting PHONE # 714 - 975 - 4257 <br /> ADDRESS 9595 Lucas Ranch Rd . ,� Rancho Cucamonga , CA 91730 <br /> SIGNATURE ` \� 52tif/y DATE 12/ 11 /2022 <br /> 2of6 <br />