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SANJ 0 Q U I N Environmental Health Department <br /> C Q l-J ICI T Y 11 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> YKS K RMLY EXPIRES 1 BG DAYS FROM THE APPROVAL GATE_ I NOICATE PERMIT TYPE BELOW: <br /> ❑TANK RETRORT O PIPING REPAIRIRETROFIT M UDC REPAIPJ'RETROFIT El COLD STARTlEVR UPGRADE <br /> F EPA site 4 Prooct Contact&Telephone N filbert Barajas {908) 213- 266 <br /> c Facility game Pilot FI 'ng J 618 Plwne# (888) 97 -7581 <br /> Address 1501 N Jack Tone Fed Ripon CA 95866 <br /> Cross Street <br /> y OwnerfOperstor Pilot Travel Centers L LC Phone# 4 4 1-62 2 <br /> C ContractorName Jones Covey Groue, fnc. Phone# 909 97 -7581 <br /> T Comractor Address 9595 Lugs Ramn Ro.ArtQP,Ranciia i`ucar cfflga�CA 97730 CA LiG# 81 44 1 Class A.B,Haz,O-10 <br /> A Insurer Msurance Company of the West woFk Camp# WVA5068 8 0 <br /> T ICI"Technician's blame Expiration Dale <br /> I� <br /> ICC InWallor's name Explradan Dale <br /> Tank system work area Tank Size Chemicals Stared Currently Dale UST <br /> I1.&1I� .�,91leakdeleaar,U6CM4tbo Installed <br /> r T-3 Mwel$TP Sump 20,000 gal diesel <br /> A Bio-Dl$sel Transitlan Sump <br /> N <br /> K <br /> Approved ❑ Approved with conditions Disapproved <br /> I. (See Attachment Wilh Conditions) <br /> A <br /> PJan Reviewers Name Date <br /> APPLICAWr MUST PERFORM ALL WORK IN ACOOFWANCE WfTI1 SAN}pAQVHH,1 COUNTY 0RDINANrI!$,STATE LAW$,AND RULE$AND REGULATIONS OF SAN <br /> JO+CLAN COUNTY, I:WP*NMF=NTAL HEALTH DEPARTMENT_ OWNER OR LI-ENSE0 AGENTS S16NATURE CERTIFIES TKE FOLLOWING: 'F CERTIFY THAT IN <br /> THI*PERFCRMANCi OF THE WORK FOR WHICH THIS PFRMrr IS ISSUED,I SHALLL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 9EC W15 5UBJ8CT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR &USCONTRAGTrNG BIGNATUHv� uffATIHI $YIiE r'0L44iwrNG! `I CEFtTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK rOR WH14:H THIS PERMIT*ISSUED,I$HALL EMPLOY PERSONS SV Er,'T TO WORKER'$COMPENSATION LAWS <br /> OF CALIFORNiA' <br /> Assistant En+rironrrleHttul <br /> Appkar4'a 9ignalum T111e Cam lianre PM Case 0912412025 <br /> BILLING INFORMATION; <br /> Indicste the responf>ible party to be billed for addittonal EHfD staff time expended beyond permit paymem coverage per <br /> tank. If the party design13ted below Is different than the permR applicant, e.g. property owner, the party must <br /> acknowledge thl s responslblllty for the blifing by signature and date below. <br /> Assistant EfivirunmCnlal ( 0 ) 1 _5 66 <br /> NAME I�P I i3r $ TfTlE Comntiarlce Ek PHONE tl <br /> ADDRESS 9595 Lucas Ranch Rd. Rancho Cucamonga. GA 91730 <br /> SIGNATURE a& i - DATE 09130/ 0 5 <br /> 2 Of 6 <br />