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' N J O A U I Environmental Health Department <br /> —COUNTY— <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OFF PIPING REPAIR PERMIT <br /> THI S PERMIT EXPIRE$1 U9 DAYS FROM THE APW�UVAL QATE_ I NOICATE;PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT O PIPING REPAIFURETROFlT 2 UDC REPAtRIRETROFIT 0 COLD STAtTJEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone 4 Albert Barajas (909) 21 -5266 <br /> C Facility Name Pilot Fly!n g J 6 1 Phone (888) 972-75,51 <br /> � Address 1501 N Jack Tone Rd Ripon CA 95366 <br /> 1 Cross street <br /> T <br /> y OwnerlCperatcr Pilot Travel Centers LLC Phone# 424 251- 222 <br /> � Contractor Name Jones Covey GrOUp, Inc. I= are# 909 972-7581 <br /> i Contractor Address 9595 Lucas Ranch Rd.#1GO,RAFchoCucamanga,CA 91730 CA Llc# 8044 1 Class A,S,Haz, -ill <br /> R Insurer Insurance Company of the West Work Camp* WVA,506868302 <br /> T ICC Technician's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank systarn wank area Tank size Chemicals Stared Currently Tate UST <br /> P.O.a7 oro1rha ja.4.e+"00V. w,upc Tn.dICQ Installed <br /> T Blo-!!last SNd Surnp <br /> A <br /> N <br /> FC <br /> P Q Approved f Approved with conditians ❑ Disapproved <br /> L (see Attachment Wilh G4md Ilion s) <br /> A <br /> Plan Reviewers t%lame Data t <br /> r <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN IOAgUIN COUNTY ORI]INIAWES, STATE LAWS,AND RULES AND RECA LAMN IS OF$ M# <br /> QAQUIH COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICFNSFb AGE-;WrS SIGNATURF CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORT{POR WHICH THIS PERMIT IS 2,%CI O,I$HAIrL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SLWECT TO <br /> WOR14VW$ COMAPENSAT" LAWS OF CALIFORNIk* CONTRACTOR'S HIR4NG OR SUBCONTRACTING SIGNATURE CERTIFIES THE F❑ l-GWING: 'I CERTIFY <br /> THAT IN THE PERFORMANICE OF THE WORK FOR VMICH TWS PERMIT IS ISSUED,I SHAt L EMPLOY PERSONS SUPJECT TO WORKER'$COMPENSATION LAWS <br /> F CALIFORNIA.' <br /> Assistant Environmental <br /> rpPlicant's S E� TIU60 i n rime 06/12/2025 <br /> BILLING INFORMATION: <br /> Indicate the responsible patty to be billed for addilional F-Np staff Urn@ 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 /> aCknowledga this responslbiRy for the bl Ili rig by signature and date below. <br /> Assistant Envlronrnental (909 213-52 6 <br /> NAME Albert Barajas 71T't_E PHONE 4 <br /> ADDRESS 9595 Lucas Punch Rd. Rancho Cucamonga, CA 91730 <br /> $IONATl1RE � � DATE 0 /12/2025 <br /> �i{, <br />