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SANJOAQUIN 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 /> ❑ 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 <br /> C Facility Name Pilot Travel Centers LLC Phone # ( 800 ) 562 - 6210 <br /> � Address 345 Roth Rd . , Lathrop , CA 95330 <br /> 1 Cross Street <br /> T <br /> Y owner/operator Pilot Travel Centers LLC Phone # ( 800 ) 562 - 6210 <br /> C Contractor Name Jones Covey Group , INC . Phone # ( 909 ) 972 - 7581 <br /> N Contractor Address CA Lic # Class A, B , Hez , C- 10 <br /> T 9595 Lucas Ranch Rd . , Rancho Cucamonga, CA 91730 804431 <br /> A Insurer Starstone National Insurance Company Work Comp # T10231330 <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 /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2 , etc. ) Installed <br /> T Tank # 1 Unleaded 87 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date <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." DD <br /> Applicant's Signature 10ee�tt 5 Title Permits Date 8/8/23 <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 Permits PHONE # 714 - 9754257 <br /> ADDRESS 9595 Lucas Ranch Rd . , Rancho Cucamonga , CA 91730 <br /> SIGNATURE 0 '� � ` "� DATE 8/9/23 <br /> 2of6 <br />