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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209) 468- 3420 Fax : (209) 46 &3433 <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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Karli Karns (661 ) 631 -3870 <br /> A <br /> C Facility Name YRC, Inc. Phone # (209) 833- 1408 <br /> I Address 1535 E . Pescadero Ave , Tracy, CA <br /> L <br /> I Cross Street North MacArthur Dr <br /> T <br /> Y Owner/Operator Richard Phone # (209) 833- 1408 <br /> C Contractor Name Confidence UST Services , Inc. Phone # (661 ) 631 -3870 <br /> O <br /> N Contractor Address 16250 Meacham Road , Bakersfield , CA 93314 CA Lic # 804904 Class Haz A, C61 - D40 <br /> T <br /> R <br /> A Insurer State Insurance Fund Work Comp # 1308371 -2018 <br /> C <br /> T ICC Technician 's Name Frank Amestoy Expiration Date 11 /14/2019 <br /> Q <br /> R ICC 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 Tank 6 (Waste Oil ) 6000 Waste Oil <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L P-� (S Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name ' Date <br /> . � r_ <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." �i /� <br /> Applicant's Signature <br /> /l Gil �G / l Gi 40al Title Karli Karns Date 03/27/2019 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank . If <br /> the party designated below is different than the permit applicant, e . g . property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Karli Karns TITLE Dispatch , Confidence UST Services PHONE # 661 -631 -3870 <br /> ADDRESS 16250 Meacham Road , Bakersfield , CA 93314 <br /> SIGNATURE aA�& /0,31� a4ydtZ DATE <br /> EH230038 (revised 7-26-2016) 2 <br /> E <br />