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Environmental Health Department
<br /> SANvJOAQUIN Environmental Health Department SANAJOAQUIN
<br /> COLINTY— ---, C OUN TY
<br /> ---
<br /> - Grcntnass gmlus hrva
<br /> APPLICATION FOR UNDERGROUND STORAGE TANK
<br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT
<br /> RETROFIT OR PIPING REPAIR PERMIT i SPEWrm ExPIRESIWDA" FRONTREAPPROVALDATE. PIDICATEPERVITTY ULOw.
<br /> ❑ TANKRETROFIT D PIPING REPAIR/RETROFIT DUDCREPAIRIRETROFIT OCOLD STARTIEVR UPGRADE
<br /> [ ] 1 , Submit all information in triplicate- Answer all questions, leaving no blanks. One copy will be returned A EPA Site # Project Contact & Telephone Rob Sills (714) 975-4257
<br /> to the applicant with comments. C Facility Name Pilot Flyinit J618 Phone # (209) 339-4066
<br /> [ ] 2. Include a detailed site map on a separate sheet of paper showing all work to be done. Include Address 1501 N Jack Tone Rd., Rion CA 95366ude the L P
<br /> location of the lanks(s), piping, all tank-related appurtenances, streets, adjacent properties (north toward T Cross Street
<br /> the top of the page), nearby septic tanks, leachfields, water wells, buildings, underground public utility v tTxTerppemtor Pilot Travel Centers LLC Phone # 209 339-4066
<br /> tines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. ( )
<br /> If underground utilities are not included on the she map, you must state in writing that USA Dig will be c Convector Name Jones Covey Group, Inc, Phoma # 909)972-7581
<br /> contacted prior to excavation activities. 14
<br /> T Contractor Address OHS Lucas Rand) R0. Rancho Cucavdga, CA917aO CAOc # 804431 Class A, B, CIO, HA2
<br /> [ ] 3. Complete pages 36, -APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR A Insurer Berkshire Hathaway Homestate Insurance Company work camp # JOWC320551
<br /> PIPING REPAIR PERMIT-. OTE If sampling is reouired. sampling firth shall bean independent third CT 1 ICCTedvldans Name Issac Garcia Expiration Dale 8192172
<br /> Party from the contractor cedortnino the work.
<br /> °a ICC Installers Name Issac Garcia Expkatwn Dale 8192172
<br /> [ ] 4. Complete page 7, -Authorization to Release-. This form must be signed and dated by the Tank system work area Tank Size Chemicals Stored Currently Date UST
<br /> OWNERIOPERATOR of the facility. A.erove"=-P.+, eweem-.iec ,2ml Installed
<br /> [ ] 5. Submit a completed -Service Request- form and 'Underground Storage Tank Program Fee T UDC #14/15
<br /> Worksheet-. A T-4 87 Annular L-10 12,000
<br /> N
<br /> [ ] 6. If performing any excavation activities, and the facility is located outside of the dry limits, submit a K T-1 DIESEL ANNULAR (L-7) 20,000
<br /> "Backfill Excavation Certificate" as required by the San Joaquin County Building Department. If a T-5 91 ANNULAR L-11 12 000
<br /> "Backfill Excavation Certificate" is required by any incorporated areas (cities). submit to the
<br /> appropriate City Building Departments, pursuant to the Uniform Building Code STD 70.11.
<br /> [ ] 7. The maximum review lime for Pian Review is 15 working days from receipt of the add uate p El �� [ Approved Win Disapproved
<br /> contlitlens ❑
<br /> completed plan. If gross deficiencies are Identified, an addendum will be required with a $152.00 per
<br /> hour fee and the review will begin on the date of resubmimal. q Sod Attachment With in Conditions)
<br /> [ ] a. Advance Inspection notice of at least 48 hours is required by the N Plan Reviewers Name Data
<br /> Environmental Health Department (END), i PF nOUST CFUJ A11 wows IN Arv .NJAOu
<br /> ACCOADANCE %Vm SwCOIArrf oaowura:ES, STATE UWS, MD RUES Acv REGUAnONs of SAN
<br /> 1courm. FavwonTA<imAL saxTN oEPARTUErm. gA+IER oa ucENSEo AgENrs sxvuTsmE cERnFIEs THE F«LOArug: � CERTIFY rrur w
<br /> [ ] 9. Contractor to Provide: Combustible/Flammable gas detector (to verify the Lower Explosive Limit ms cow NSE Foce MgrEOXio or��r cArouaorEar suecrTor
<br /> (LEL) atmosphere and oxygen level), adequate number(s) and appropriate type(s) of fire extinguisher(s), gRuarcE of THE vroRxFoawlnw Trvss PFJwR Is IssuEo, I swu FUPLor PeasoNs sLa,EcrTo woRlaRs covPaNsnrwN uvrs
<br /> and barriers to secure the area as necessary to minimize traffic and pedestrian interference. It shall be ore
<br /> the project manager's responsibility for compliance with all health & safety regulations and requirements, Ote4 Gc0" rm Jones Coy Group - Permh 12/8/2022
<br /> Including confined space requirements, which shall be strictly adhered to at all times during the course of
<br /> the underground storage tank (UST) activities. BILLING INFORMATION:
<br /> [ ] 10. The EHD permit shall be on site during all UST permit•related activities. Indlwle the responsible party to be billed far additional EHO staff time experded beyond permtt payment coverage per
<br /> tank If the party designated below is different than the permit applicant, e.g. property owner, the party must
<br /> [ ] 11. Any changes acknowledge this responsibility for the biTIkg by signature and dale below,
<br /> g in this document shall be approved by the EHD prior Initiating work. All changes to
<br /> any work must be described in detail on pages 384 and be shown on thea Robert site map. rvaAE TIRE Jones Covey GlWp - Permtttirg pNONES 714-975-4257
<br /> ADDRESS 9595 Lucas Ranch Rd.. ##100, Rancho Cucamonga CA 91730
<br /> SIGNATOR j161641 Sa DATE 12/6/2022
<br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464,0138 1 www,sjcehd.com 20(6
<br /> SAN JOAQUIN Environmental Health Department SAN JOAQUIN Environmental Health Department
<br /> ----- COUNTY -- -- - COUNTY—-
<br /> UST SYSTEM RETROFIT OR REPAIRDescribe method to be used for decontamination:
<br /> (Submit minimum of 3 sets of plans & applications as originals Wit be retained by EHD)
<br /> 1. Site map enclosed? YES [4 NO [ 1 d. Des 'be how rinsate material will be stored onsite prior to manifesting ogsite:
<br /> 2. Submit copies of ICC Service Technician andlor Installers certificate and all manufacturer training
<br /> certificates for each person installing or testing any component that is repaired or replaced. Ensureacopyof
<br /> the 'Site Health and Safety Plan' Is available on the jobsite as required by Tide 8. e. Rinsate Ha er and permitted Treatment, Storage 8 Disposal Facility:
<br /> 3. Detailed description of work to be completed. List components to be repaired or replaced and attach a Hauler Name Phone Hauler Reg#
<br /> diagram drawn to scale showing location of repairs and/or replacements. If repairing a component, describe Address Ciry Zip
<br /> how this will be done. (Ifda ding piping, UDC's, or other UST equipment, or performing tank top upgrade,
<br /> use the UST Installation Application pages 4.8 as necessary for a limey plan review): Permitted Disposal\e
<br /> e
<br /> -UDC #14/15: Install Bravo Retrofit entry kits inside UDC - (3) 3" at products (1 ) 2" at vapor.
<br /> 6. a. Describe the method that 'll be utilized to purge and/or inert the piping:
<br /> -T-4 87 Annular L-10: Break ground and replace 40 FRP riser pipe Including (2) 4° BxM
<br /> adapters. ReplaceMstall new 24" manway. b. Piping Hauler.
<br /> ANNULAR RISERS ALSO REPLACED AT: Name Phone (_]
<br /> -T-1 DIESEL ANNULAR (L-7) Address Ciry zip
<br /> -T-5 91 ANNULAR (L-11 )
<br /> Hauler Registration # (if hauled as haze oust
<br /> c- Piping Disposal Site:
<br /> Name Phone �)
<br /> Address City zip
<br /> EPA ID# Qf transported We permitted TSD facility)
<br /> 4. List of equipment to be used (Attach manufadurees specification sheets showing third-party approval): 7. Is the sampling firm an Independent third parry from the contra ort YES [ j NO [ ]
<br /> 3 - Bravo Retrofit PM: RF-30.01-U a. Identify sampling firm:
<br /> Name hone( l
<br /> 1 - Bravo Retrofit PM: RF-20-01-U Address Cl Zip
<br /> TBD - NOV 4" pipe PM: 012040-240-0 b. Identify laboratory performing analysis:
<br /> 6 4 - NOV 4" BxM PIN: 012940-1914 Name Phone
<br /> 3 4 - OPW24" ManwayP/N: 6110-241AF1- Address Ciry zip
<br /> 8. Describe, In detail, how the soil andlor water sample(s) beneath the piping or dispe erwill be obtained:
<br /> S. a. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler):
<br /> ination Procedures: Name Hauler Registration # Phone
<br /> a. W II pipingmated prior to removal? YES [ ] NO ( ]
<br /> b. Identify contractor donning on: Address Ciry zip
<br /> Name b. If sol Is not to be hauled, describe what will be done with it:
<br /> Address City p
<br /> 306 40(6
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