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Envlronme� f.;At-.'-�SAN 0AQU N kT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK NOV 2 N18 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATEINDICATE PERMIT TYPE wlb I R N MENTAL H <br /> EAL r <br /> H <br /> ®TAMCRETROFIT ❑PIPING REPAIRIRETROFIT ❑UDCREPAIRIRETROFIT D COLD STARTIEVRtr-WFEN_ <br /> F <br /> EPA Site# CAL000292946 Project Contact$Telephone III Zachary D.Fein old <br /> A <br /> C Facility Name Verizon Business: LDIKCA Phone# 909.879.2712 <br /> I Address 2500 W Turner Rd, Lodi, CA 95242 <br /> TCross Street <br /> Y 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 Insurer Midwest Employers Casualty Company Work Comp# 13NUWC0140939 <br /> G ICC Technician's Name Expiration Date <br /> T <br /> R ICC Installer's Name Expiration Date <br /> Tank system work areaTank Size Chemicals Stored Currently Date UST <br /> (Le.IT Peng rump,01 Ind detector,UDC Id2,etc) y Installed <br /> T Turbine Sump 4,000 al Diesel 04101/1991 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( e A hment With Conditions) <br /> A <br /> N Plan Reviewers Name Q Date , zz <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR H SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK f D GH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> +NORKER'S CDMPENSAT LAI C FORMA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM E DF TKWORK F WHICH THIS PERMIT I5 ISSUE[),1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ` <br /> APPticWil Sipnllure '�. Tift DIIe i <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional E H D 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 Vanes rte a TITLE Project Manager PHONE# 909-594-9830 Ext 8014 <br /> ADDRESS 478 Cheye ne Way, Chino, CA 91710 <br /> SIGNATURE DATE- <br /> 2 of 6 <br /> ATE2of6 <br />