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SA N J O A Q U I N Environmental Health Department <br /> — COUNTY --- - <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 P9 PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Yana Khegahy (714) 761 -5426 <br /> A <br /> C Facility Name Colonial Energy #40135 Phone # <br /> I , <br /> L Address 192 LathropRdLathrop , CA 95530 <br /> 1 Cross Street Harlan Rd <br /> T <br /> Y Owner/Operator Colonial Energy , LLC Phone # 714-761 -5426 <br /> C Contractor Name Corona Fueling & Electric, Inc. Phone # 562-762-8492 <br /> N Contractor Address PO Box 6219 , Whittier, CA 90604 CA Lic # 952213 Class A , Haz <br /> T <br /> R <br /> A Insurer Starnet Insurance Work Comp # BNUWC0135197 <br /> T ICC Technician 's Name Expiration Date 4/15/2021 <br /> T Brian Burns p <br /> R ICC Installer's Name Brian Burns Expiration Date 8/11 /2022 <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 Convert (e) 87 Slave UST to E85 20 , 000g 87 Gasoline 1 / 1 / 1995 <br /> A New Dispensers <br /> N <br /> K New E85 Product Piping <br /> P ❑ Approved AApproved with conditions L1 Disapproved <br /> L chment With Conditions) <br /> A ` ( , I <br /> N Plan Reviewers Name � e �' � Date / � �C� <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 /> Applicant's Signature Title Date <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 Victor Hassan TITLE President PHONE # 714-761 -5426 <br /> ADDRESS QAn M -Qnnfinnn Plyd , Orancie . CA 92867 <br /> SIGNATURE �^'�- DATE 10/7/20 <br /> 2of6 <br />