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'A N J O A Q U I Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXfYIRE5 180 DAYS FROM THE APPROVAL DATE_ INDICATE PERUT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRfRETROFIT R UDC REPAIRfRETROM f]COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# AlbeTt Barajas (909) 13-5 66 <br /> Facility Kama ,Pilot FI kn J 618 Phone# {888) 97 -7581 <br /> Address 1501 N Jack Tone Rd Ripon CA 95366 <br /> 1 Cross Street <br /> T _ .. <br /> y OwnerlCperatar Pilot Travel Centers LLC Phone# 4 4 51-6222 <br /> C Contractor Name JorleS Covey Group, Irtc. Phone# 909 97 -7581 <br /> TContractflr Address 1I59S Lucas Randy Rd_NIOd,Random Cucsmonxda,CA 9173a CA Lic# 804431 Class A,B,H az,C;10 <br /> A Insurer Insurance Company of the West Workcomp# WVA50686830 <br /> ICC Technician's Flame Expiration Date <br /> R R FCC Installer's Name Expiratlon Dale <br /> Tank syslem work area Tank Size Chemicals Stared Currently Cate UST <br /> 4k4.a?Pq?kq Bump,IN lack MI*cx_{IBC 112_i4C I InsudInd <br /> T Sla Shed Transllinn Sump — <br /> A N.Diosai Transllron Sump{LA1 <br /> N <br /> K S_Diesel Transition Sump(LION <br /> p Approved Approved wilh conditions r1 Disapproved <br /> L pee Attachment With Condlllons) <br /> N Plan Reviewers Nana Date <br /> APPLICANIT MUST PERFORM ALL WORK113 ACCORDANCE WITH SAN JOAOUIN COLWTY ORDINANCZS, STATE LAWS,AND RULES AND IkEryLJLATkON$OF$AN <br /> JOAQUIN COUNTY,Eh RONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING- 9 CERTLFY THAT IN <br /> tNl;PSIiFtCRMANCI=OF THE WORK FOR WHICK 11415 P15RMtT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON W SUCH A MANNER 46 TO BECOME SLIBJECTTo <br /> WQRKr;Fr$ COMPI*NSA7ICN LAWS OF CALIFORNtA.' CONTRACYdk'S HIRLNG OR SUF�C4NYRAC71NA SIC3NAYURF GERTIFIF.$ TF[F PGLL4WIRG' 'I C8R11FV <br /> FLAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IS$UED,I$HALL EMPLOY PERSON$SUBJI GT TO WORxER'S C0UFEN$AT10N LAWS, <br /> OF CALIFORNIA' <br /> Assislant Environmental <br /> canna s,j��.,n ru J' TUIe Coln iance PM Daso 0410812025 <br /> BILI-ING INFORMATION: <br /> Indicate the responsible party to be bflled For additional EH staff time expended beyond permit payment coverage per <br /> tank_ R the party designated below is different than the permil applicant, e.g. property owner, the party must <br /> acknOvA$dge this ra$pH nsi bility for the billing by signature and date below_ <br /> Assistant Environmental NAME Albert Barajals T1nE_QMnp anCePM PHONE# (909) 1 - C <br /> ADDRESS 9595 Lucas Ranch lid. Rancho Cucamonga, CA 01730 <br /> SIGNATURE Mlit MTF 0410812025 <br /> 2of6 <br />