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SA N JOAQUIN Environmental Health Department <br /> . ,' TY <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 /> 1 Cross Street <br /> T <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-10 <br /> A Insurer Insurance Company of the West Work Comp# WVA506868302 <br /> TICC Technician's Name Expiration Date <br /> RICC Installer's Name 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 <br /> A N.Diesel Transition Sump(1-8) <br /> N <br /> K S.Diesel Transition Sump(1-10) <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." <br /> Assistant Environmental <br /> �e4 Applicant's Signature (ti ,t,r B � Title Compliance PM Date 04/08/2025 <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 Barajas TITLE Compliance PM PHONE# (909) 213-5266 <br /> ADDRESS 9595 Lucas Ranch Rd. Rancho Cucamonga, CA 91730 <br /> SIGNATURE DATE 04/08/2025 <br /> 2 of 6 <br />