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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT S AN r10AQ U I N Environmental Health Department SERVICE REQUEST —COUNTY— Type of Business or Property FACILITY 10 SERVICEREQUEST # Fueling Facility SAMPLING PROTOCOL FOR ROUTINE PIPINGIDISPENSER REMOVAUREPLACEMENT OWNERIOPERATOR The folowktg represents minimum samppng criterion required for dosure compriance. Sol samptes collected shall he Pilot Travel Centers, LLC GrECAif EnIWG "amess0 Samples pcannot be ombinenaive scOs d Into a compositeath the sample for Ws aoam)IstIn the field or the b,not 1. Each sample mush Factual Flying J #6181 Pilot Travel Centers, LLC hava set of corresponding analytical results. If conlertrtalan Is documented during closure, an Unauthorized SREADDRES6 N g Release Notification must be completed and submitted within five (5) working days pursuant to California Health a 1501 N Jack Tone Rd, Ripon CA 95366 Safety Code, Section 25295, HUIIEOl MALINGADDRE66 pr Dlhenenthorm She Address) DISPENSER PIPING AND STOCKPILE SAMPLES _ DISPENSER SAMPLES tSample beneath each Gspenser Cm STATE ZED PIPING SOIL SAMPLES i Sample every 20 ictal fee[ PBuxEIR E^• "us Luno UsE NKWATMNI 1 1 DISPENSERS PIPING STOCKPILE SAMPLES 25amples every 50 able yards PNONEi2 Ea, Roe DYT=T LOCARNN CopE 1 1 CONTRACTOR / SERVICE REQUESTOR TABLE #2 RECOMMENDED MINIMUM VERIFICATION ANALYSES RE2IUESTOR CxscNif RILuro AODREss■ Rob Sills - Jones Covey Group, Inc, FOR UNDERGROUND STORAGE TANK INVESTIGATIONS e" Busm6ss NAME ,)piles Covey Group, Inc. PxoAE# 975 . 4257 ' 714 TANK TANK Gasoline Diesel BTEX VOCs0l Saint. 0118 PCB Total Title 22 Housor MAwIGAODRESS Full # CONTENTS VODsrn orease Lead eta sit 9595 Lucas Ranch Road #100 ( 909) 484.0300 UISIA60B SOISAI 02608 82608 8082 7421 CITY Honcho Cucamonga STATE CA � 91730 82608 82]OC 169/0. UnFraan Fuel BILLING ACKNOWLEDGEMENT: I, the undersgned property or business owner, operator or authorized agent of same, X x x x acknowledge that as she end)or project specific ENlnaa:uExrAL HEALTH DEPARTYFIm hourly doges associated win this project or (GC36) activity will be billed to me or my business as Identified on this form. Ga tiro ttt(C4Sei % X X I also it Ord that I have prepared this TATE end and that Lite work b be performed w01 be done N accordance vAN all Sul Joaeuw (Cl X X X Doom Ordinance Codes, Standards, STATE end FEDERAL laws. (CIO—C38) 7 �. �+� ff Jet FuWKre esere X X APPLICANTS SIGNATURE: /�OGriLT 72G1b DATE: 12/6/2022 (C9C20) Heabre 04 PROPERTY I BUSINESS OYMERD OPERATON ) MANAGER 13 OTNERAUTHORIZEDAGERT 0 Jones Covey Group - Pernilting (ClO 2) X X If APPlleulrismflheBuwoPARTY. proorur authorization to Sign is required Title Sotldead Sphere AUTHORIZATION TO RELEASE INFORMATION: When applicable, I. Ne owner or operator of Ne property orated at the above fnan-�cNpohnizea) X X site address, hereby authorize the release of any and all results, geotechnical data and.br envifonmentallsite assessment information Com. ley to the Sun JoAoucn Couun EmARceluserT& HeiLTH DEPARiuEM as soon as R is evdiaNa and at The same time it is provided to me or Sohens X X my representative. unlassuan waste Of or X x x X % % x TYPEWSERNOEREQVESrso: UST Repair Permit App Coarsens: -UDC #14/15: Install Bravo Retrofit entry kits Inside UDC Noes: -T-4 87 Annular L-10: Break ground and replace 4" FRP riser, and replace 24" manway, 1. EPA Wosod 82608 analyses must include a anahtes urea F Ne method Plus NO oxygenates methyHenarybutyt eVNr ANNULAR RISERS ALSO REPLACED AT: T-1 DIESEL ANNULAR L,,7), AND T-591 ANNULAR (L-11 ) (MTBE), C,sopopyl elver tDIPE), eNN-temanyMgl ether (ELBE), teNaryanyfnretl0l e]or (TNJE), tadarybvland (TBA), methanol and ethanol am NO aeld tees 1.2Ek2doraeUax (1,2-13CA) am ethylene dAvomlde (EOR or 1,2- drWmoemare). ACCEPTED BY: EYPLOYFE #: DAre: 2. Ifpusachabrophend (PGP) is Identified, analyze Ne sol andb water sample far drx'ns and hisens by EPA Method 8290 ASSIGNEDIou I DAIS: and peslcidesby EPALteOod BOB1A Data Service Completed (haiready completed): sarecECOeE: PIE: 3. TNe22Melais: IJetos 60108 may he used for eE Wl tofoaacvyg melelz. lorwM1'ch edHdsal AA methods are requked: Fee Amount: Amount Paid Pe ¢Pat Date Arumony A Arsenic by 7062, Cadm'um by 71310. Lead by 742t, stercury by7471A, nickel by 7521, Seln mby 7742, am Ym n Tha'lumby7841. Payment Type Involve # Cheeks - Received By: 4. Non-poprkury. performance based a alytoal metods may he used with approval of ReguarJ Roars staff. Sd6 EHD 48-02 (X26 SR FORM (Gilden Rao) 07/t]A0 SAN JOAQUIN Environmental Health Department a JONES COVEY GROUP, INC . COUNTY---- �.UttVi.E -t E FUEL ;'r:i iLlQ LUIJS rRUC I10 0 t.'JtG'1 i ENANCE SERVICES AUTHORIZATION TO RELEASE • ANALYTICAL RESULTSr . . CONTRACTORSP • GEOTECHNICAL DATA STATE LICENSE BOARD C� )Swr,< „ Licensees Applicants Or • ENVIRONMENTAL /SITE ASSESSMENT INFOR.\/ATION GConiractor's License Detail for License # 804431 DISCLAIMIlh Aiieerse status ch"Itprov(des information taktafrem Ne Cite trials databue.aAererelyin#an this ], THE UNDERSIGNED OWNER AND.DR OPER-{TOR OF THE PROPERTY ANDJOR FACILITY LOCATED AT Infulmadon,you should as aware lathe fellewln3Rmitauens. (S1rrelAddrieu) (city) ' nnlappraroocw toras�relnfermx(x•'P.ck M;13a deflnrarns otdudaabb:caroc�is Lmpalnrc;cfosJrcdic:onUnk U.v HEREBY AUTHORIZE t Oaliconnrv:doe related chxtwdyons reared rWCXB arediscieset (W 1011.27), (Laborafu0) t Art trari rsaienx Ls•ed un;csstla vnoattertzstoramFhlwantleroms. t We toxMlead.dom mare. rdvant ;nlamtatwntnal MarKKYtTOomenxved tiro for Lased steonx datanalani 70 RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND ATTHE SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE BUSINESS NAME: (7f 4upheahle) JONES;COVEY GROUP INCORPORATED 9595 LUCAS RNICH ROAD 01VNER: RANCHO CUM'IGNGA,CA 91730 (Plenze Printf (rind Bus:nnss PjoneNumber:(oY)) 972-7581 f0ifeersignalYlr) (Dale) Entity Corporation Issue Date 02r2112o(y2 ADDRESS: Expire Date 0913112023 (Iro)flng Andreas) (00) (Star) (Zip Code) This license is calrent and active. PHONE: All information below should he reviewed. t A- GENERALENGINEERRIG t a -GEN RALBUILOING t Clu - ELECIflI[AL i Certifications I RS11524�i'SL'd5+b1ii3Hf3iY sole 5505 LUCAS RUIOI ROAD. ROIChO CUC.WkIG A, CA 51730 - CA UCTN5F3 tO 31 A. 8. HAT - LICEIMI) 14 415TATES