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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br /> SERVICE REQUEST SAN JOAQUIN Environmental HeaaltfhSDepart
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<br /> OMERIOPEMTORAPPLICATION FOR UNDERGROUND STORAGE TANK DEC 16 2022
<br /> Pdol Travel Centers, LLD c,E«Meu,ro ASeuas❑ RETROFIT OR PIPING REPAIR PERMIT
<br /> FMamNalEToms PERwrEMlREs tmwra YapaTE ArPRwK ahs W... rnsarneeaoe�NVIRONAIENTAL HEALTH
<br /> Flying J 0610 / Pilot Travel Centers, LLC DTANKRETROFIT D PIPING REPAIRMETROFIT DUDGREPAIRIRETROFIT DCOLD STARTIEWOWWWRVICES
<br /> BTEAeD"Eas 1501 N Jack Tone Rd. Ripon CA 95366 FEPA step
<br /> A Protea cayaa a ralepnere r floe Siris (714) 975.4257
<br /> IImEa MMlase ADoness Of Different been Silo Address( QFCFNr i FegMy Name Pilot F 1 J618 Phone 209 339,4066
<br /> / Address 1501 N Jack Tone Rd-, Ripon CA 95366 i
<br /> Errs STATE �" OfC V�0 Cross street
<br /> Poa= pl Ea. "of LMmwEAPYaKArhox . Ay,,D X117 j y Ownersoperator Pilot Travel Centers LLC Pllalea209) 339.4066
<br /> HEEM'IROU/N O(]Ar c Conlrador Nam. Jones Cove Group, Inc- Plpo. a (909 972-7581
<br /> Pr.mFAE un 00.9 DIS11rICT loulloxC 'Pq ' rAl N RCMCk)( Address
<br /> ( t AIENT n u rias La.a Ra relit. Rance a,Pararg., cAanao CA LIoa804431 pose A. B, Cfa, HAZ
<br /> insurer eed(shire Hathawa Homestate Insurance Com an wodccomp#JOWC320551
<br /> CONTRACTOR lSERVICE REQUESTOR ; IC CTedlrPto4ane IssacGarcia EapaaaooDale8192172
<br /> REQUESTOR Rob SB9 -Jones Covey Group, Inc. Clarrlla, r�- �M.-y q ICC WIeSefS Name IB6aCGarcla EIon4albn Date 6192172
<br /> Buswess NAME Jones Covey GmuA Inc. 8714 975 - 4257 � a.Melo l��y:ia°1"+ar�,e.tvereactaeua Tank Sas Chenucals Stared CurrerAy DIrr�Wed
<br /> Houeor MAaaGADDRESS 9595 Lucas Ranch Road 0100 Fut 9091 /84.0300 T Diesel Dispenser #26
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<br /> Cin Random CAlcanenga STATE CA Zr 91730 N
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<br /> BILLING
<br /> krowte ACKNOWLEDGEMENT: I, be urldenilylad property a business owner, opanla a authorized W ll ads pooled
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<br /> aamawedge the! dS i'e ormy urine spas Ide E1nAnonthis At HFKTx DEPM14F1n trolly charges associated wiN thts Argas a
<br /> EankYvAll be abed b ms a mY business as kbnlifled an Ws lam. -
<br /> I also cuNty that I lave prepared this appk ation and that She work to be performed will be done In Ettnrdance wish as SAM JoAauw
<br /> Cou9n OrteMn[n Cadet Slarerads, STATE and FEce]tK laws. �]
<br /> APPLICANTS SIGNATURE: 12/1512022 I P ❑ Approved r `AppetevedwitlmndlHwu � Dlseµvwed
<br /> 0i L1 3 a DATE: LA (See AtlachnanlwM Conditions)
<br /> PRosaw/ BusinessowuEaO OPEMTOR/MAIIADER O OTHERAumoaaEa Aseint 0 Jeno" Covey Greup - Pemku
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<br /> #AUvtx:Ainrbnotlhe Beue; Pn. proolofouthodraaon to sign b required Title
<br /> Plan Revbwen Home Done 112211023
<br /> AUTHORIZATION TO RELEASE INFORMATION: when appticable, 1, the owner or operator of the property located at are above i IA15I PEtaornl KL wpa AOCoaNaE IwTH liaN ueralM taaNn IxmaaacEa STATE uwa Mn puEe Apo nGtny,TKars OF sur
<br /> site address, hereby materials the mleaso of Say old at msuRs, geolechn'Od dab "atter envkdallent shat assessment Infuriation r T MST, EMa'bnT MK IEllllt DrfMTMEn ISH EAtl sit EI COUP a48xr950. AST currant THE ALES AR q: 9 LER11iY OF S N
<br /> W 1118 SAM JuActa9 CeLN1y E'm'naAElxrK HeAtTH DEPAnnEHr a5 soorl as Ilia available and at the sane Wne a k provided to mea loeoEtuv4 coMOroE OFTEYpaf is Wm Tit9 PERWT Da95ue on
<br /> uttrae OT ssume; ,VNATuric urraNAMNNuLcey DE1blE PAT IN
<br /> nN representative. Ra LOrPENSATNRr tA" a Elawa O cO9TRAa:TMa Hnam D S1POdmUCTNa 3#aM1taE mtraEa THE mimw 1 ceTPy
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<br /> THAT OF TE WORK.Foll"WN TRS KRAaT w rsSUFM slK EurtxW PERsoH9 SIAECT TO wola4urs PE119ATpN !Awa
<br /> TYPEOFSEm1cEREousmai: USTFze C- � Mmov, I CIc_.� A ,�A.
<br /> carlans: - 06GLt i% Too Jona co Group * PomOeng lease 12/15/2022
<br /> Pump #26 was damaged by a customer vehicle- We will replace the shear valves and perform BILLING INFORMATION:
<br /> precision line test on the product piping to ensure no leaks or damage to piping Integrity- Iae,lma de responsible pa Ly a be bead ler additional END staff time expanded beyond parent payment ccvenW per
<br /> tank. 11 tie party doa'linal ed bocw Is daerent ten the permk appikaoL e.g. properly owner, the parry must
<br /> atlutsMedga las fesponslbCty fer 010 bfArg by Signature and data below,
<br /> A"Unics By, - EMPsonak DATE l27D 22 MAME Robert Sills n Jonas Covry Grap - PermAWg paalEx 714-975-4257
<br /> AsswreoTD: 11 EMPtoYEEi: DAIC j2 -fn zz AmREas 9595 Lucas Ranch Rd. #100, Rancho Cucamonga CA 91730 €
<br /> Dela Sorv " Completed ( lakeedycomphlad): / aDaYacoce:
<br /> a 2�i8 230�i yy � �a. c1
<br /> Fee Amount: g' M Amount pal /S(o• Payment Data 1 SIGNANRE r�O 61i2rt yY DATE 12!6!2022
<br /> Payment Type Invoiw0 Cheek0 33S9S.3 Reeved By:
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<br /> EHD 0602.025 art FORM (Odds Rod)
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<br /> Environmental Health Department
<br /> SAN l ` JONES COVEY GROUP, INC
<br /> INTY-- a DIU
<br /> UST SYSTEM RETROFIT OR REPAIR N Pp1FO=NI TAL HFA LIT,
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<br /> (Submit minimum of 3 Bels of plans a applications as originals will be retained by EHD) '
<br /> 1 . Site map enclosed? YES N NO I )
<br /> 2, Submit copies of ICC Service Technician and/or Instagees certificate and all mamlrectuner training 1-1 CONTRACTORS
<br /> certificates for each parson lnslefling or testing any Component that is repaired a replaced. Ensure a copy of 111111 STATE LICENSE BOARD i_. n.umdf Utttwea Appycan6 Or
<br /> the *Site Health and Safety Plan' is available on the jobsile as required by Title B. -
<br /> 3, Detailed description of work to be completed. List components b be repaired a replaced and attach a OContraetor's License Detail for License # 804431
<br /> diagram tire" to scale showing location of repays andlor replacements. If repairing a competent, describe
<br /> how this will be time. (if adding piping, UOC's, Or other UST equipment or performing tank top upgrade, DISCIAIMERIAOcanse status (lackpmMdMbformallo" uwnhem meeitolkenwmnbam. afore YCMAA on this
<br /> use tie UST Installation Application pages 4-e as necessary fa a timely plan review): InHrmation,sea should be aware of In*foll"Inslimimbw
<br /> Pump #26 was damaged by a customer vehicle and shear valves were broken, r cEaa e,apslwaa::<Insrchrtudrrcdbrhwlex,Pn]s anrebaArq�aeytn la Nruzamp:vracxl,:•.< rcacn pmt cam
<br /> nM a)p"fWwbte:ore ldormNhn.eC<k 1fAeralNbdtb+.t'on Ndbdaab:< ictii"a
<br /> We will replace the shear valves and we will also perform a precision line lest on the product
<br /> piping to ensure no leaks or damage to piping Integrity- a QAFtonpi1b' rretted yb ^D"t"grepeated toCBS are dhtmsedtg x ox. 1
<br /> , bet•a1araare mat letter ur44s[te contractor hits to<omsh ankh the lams.
<br /> -Precision Line Test
<br /> r Due N nee',' .them mel be relctvvhr idunnadon that bas naytt been earned em the toed s rcenic daMlr
<br /> •Replace both 2e shear valves
<br /> -Repaidreplace the dispenser base
<br /> -Straighten the dispenser, as well as the main door.
<br /> :( NESrnCOVEY GROUP INCORPORATED
<br /> 9595LUCASRANCH ROAD
<br /> —"'-" RANCHO CUCAMONGA,CA 91730
<br /> BuSSlesa Phone Nanbetuiew)'JT2-]Ssl
<br /> 4. Ust of equipment to be used (Attach manufacturer's specification sheets stowing thlyd-pany approval):
<br /> Entity CorpOrMion i
<br /> Musette 0L711200
<br /> Upire Date 05121JIO23
<br /> This littnne Is turrenl enJ eaive. .
<br /> All inlonnalion below should be reviewed.
<br /> 3 Saoata llnallon PraceduZit. Y d.—GFHERA IE IOtV¢.(Rat
<br /> a. Wdl gping�-de loafed pda to mmmII��mo�'vIInna�nl7�� YES ( I NO [ ]
<br /> It, kienUfycadraaaperfor n9 s B_GEIIEibtl-BULgNO
<br /> Name Is C1D_FLECTp�CAL
<br /> Address City
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<br /> 4590 LUCAS K9rOi ROM, RNgn ClklwtotlGh U 91]kl - U LKFHSEY aOelll A, B. IN2 - tKDIYD IM ail STATE$
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