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SA N 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 /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA site # Project Contact & Telephone # Bruno Espinoza (909) 543-8904 <br /> A — <br /> C Facility Name Pilot Travel Centers LLC Phone # (800 ) 562- 6210 <br /> L Address 345 Roth Rd . , Lathrop , CA 95330 <br /> TCross Street <br /> Y Owner/Operator Pilot Travel Centers LLC Phone # (800) 562-6210 _ <br /> o Contractor Name Jones Covey Group, INC. Phone # (909 ) 972-7581 <br /> T Contractor Address 9595 Lucas Ranch Rd., Rancho Cucamonga, CA 91730 CA Lic # 804431 Class r A Br HAZ <br /> - <br /> A Insurer Starstone National Insurance Company Work Comp # T10211051 <br /> T ICC Technician's Name Isaac Garcia Expiration Date 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 /> (La, 87 plping sump, 91 look delectw, UDC 112, ow) Installed <br /> T 91 Gasoline Dispenser #7/8 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment Wlth Conditions) <br /> N � . ,� �' <br /> Plan Reviewers Name � _ Date d <br /> APPLICANT MUST PERFORM At L WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAI 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: 01 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 /> [Applicant's signature Tllle Jones Covey Grou • Permitting Date 9/15/2022 <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 BATE 9/1 /2022 <br /> 2of6 <br />