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nvirone SAN. JOHQuI -D <br /> { <br /> - - COUNTY- <br /> NOV 16 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT 'A�,{VIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE W <br /> ®TANK RETROFIT I-]PIPINGREPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD STARTIEVR U 3"D MSN T <br /> F EPA Site# CAL000292946 Project Contact 8 Telephone# Zachary D. Fein old <br /> A <br /> C Facility Name Verizon Business: LDIKCA Phone# 909-879-2712 <br /> 1 Address 2500 W Turner Rd, Lodi, CA 95242 <br /> L <br /> TCross Street <br /> Y I Owner/Operator MCI dba Verizon Business Phone# 909-879-2712 <br /> C Contractor Name Sunwest Engineering Constructors, Inc Phone# 909-594-9830 <br /> T Contractor Address 4780 Cheyenne Way CA Lic# 703190 Class A, B, Haz <br /> A <br /> Insurer Midwest Employers Casualty Company Work Comp# BNUWC0140939 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Lm e7 piping Bump,81 Iesk detector,UDC 1l2,etc.) Installed <br /> T Turbine Sump 4.000 aal Diesel 04/01/1991 <br /> A <br /> N <br /> K <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 FO CH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSAT LAWS CAIJ FC <br /> RNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> rHAT IN THE PERFORMANQE OF THUWCORK WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Siprulure 1+'r" /�-� Ttlle I Oats v <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 /> NAME VanessiKrtega 1, TITLE Project Manager PHONE# 909-594-9830 Ext 8014 <br /> ADDRESS 478 Cheye ne Way, Chino, CA 91710 <br /> SIGNATURE ' DATE I- ,IP <br /> 2of6 <br />