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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 N UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Albert Barajas (909) 213-5266 <br /> C Facility Name Pilot Flying J 618 Phone # (888) 972-7581 <br /> � Address 1501 N Jack Tone Rd Ripon CA 95366 <br /> TCross Street <br /> Y owner/operator Pilot Travel Centers LLC Phone # (424) 251-6222 <br /> o Contractor Name Jones Covey Group, Inc. Phone # (909) 972-7581 <br /> TContractor Address 9595 Lucas Ranch Rd.#100, Rancho Cucamonga, CA 91730 CA Lic # 804431 Class A,B,Haz,C-1 0 <br /> A Insurer Insurance Company of the West Work Comp # WVA506868302 <br /> TICC Technician's Name Expiration Date <br /> G ICC Installer's Name <br /> R Expiration Date <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 Bio Shed Transition Sump (1-2 Diesel Line Out) <br /> A Diesel Transition Sump (1-8 Diesel Line Out) <br /> N <br /> K <br /> P ❑ Approved ❑, Approved with conditions ❑ Disapproved <br /> L See Attachment With Conditions <br /> A ( ) <br /> N Plan Reviewers Narrte a <br /> } Date I /25 20 '7!� <br /> APPLICANT MUST PERFORM ALL WORK,IN ACCORDAI`dCE 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." Assistant Environmental <br /> Applicant's Signature a&..t Title Compliance PM Date 01/06/2025 <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 /> Assistant Environmental NAME Albert Baraj M as TITLE Compliance P PHONE# (909) 213-5266 <br /> ADDRESS 9595 Lucas Ranch Rd. Rancho Cucamonga, CA 91730 <br /> SIGNATURE_ DATE 01/06/2025 <br /> 2of6 <br />