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SANJOAQUIN Environmental Health Department <br /> C t1UNTY <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 # Rob Sills ( 714 ) 975 -4257 <br /> A Facility Name Phone # 209 339 - 4066 <br /> C y Pilot Flying J 618 ( ) <br /> � Address 1501 N Jack Tone Rd . , Ripon CA 95366 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Pilot Travel Centers LLC Phone # ( 209 ) 339 - 4066 <br /> C Contractor Name Jones Covey Group , Inc . Phone # ( 909 ) 972 - 7581 <br /> N Contractor Address 804431 <br /> T 9595 Lucas Ranch Rd . , Rancho Cucamonga, CA 91730 CA Lic # Class A , B , C10 , HAZ <br /> A Insurer Berkshire Hathaway Homestate Insurance Company Work Comp # JOWC320551 <br /> T ICC Technician ' s Name Issac Garcia Expiration Date 8192172 <br /> R ICC Installer' s Name Issac Garcia Expiration Date 8192172 <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 # 14/ 15 <br /> A T4 ( 87 ) Annular ( L- 10 ) 12 , 000 <br /> N <br /> K T- 1 DIESEL ANNULAR ( L-7 ) 20 , 000 <br /> T- 5 91 ANNULAR L- 11 121000 <br /> P ❑ Approved ,Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A l / <br /> N Plan Reviewers Name Date 14: �� 1 2 <br /> - yZ� <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 /> Applicant's Signature 'O Title Jones Covey Group - Permitting Date 12/8/2022 <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 Robert Sills TITLE Jones Covey Group - Permitting PHONE # 714 - 975 - 4257 <br /> ADDRESS 9595 Lucas Ranch Rd . # 100 , Rancho Cucamonga CA 91730 <br /> SIGNATURE ' \ DATE 12/8/2022 <br /> 2of6 <br />