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SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM TWPPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> [] TANK RETROFIT ❑ PIPING REPAIR/RETROFIT EUDC REPAIR/RETROFIT Q✓ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # David Saucedo (209) 679-6516 <br /> � <br /> Facility Name Gas Depot # 2 ( ) <br /> Phone # 209 679-6516 <br /> 1 Address 1330 East Yosemite Boulevard <br /> L <br /> TCross Street <br /> Y Owner/Operator Abe Phone # (209) 679-6516 <br /> CContractor Name Confidence UST Services Phone # (661 ) 631 -3870 <br /> N Contractor Address 16250 Meacham Road CA Lic # Class <br /> T <br /> R Insurer State Fund Work Comp # 1308371 -2018 <br /> A <br /> C <br /> T ICC Technician 's Name Frank Landa Expiration Date 01 /28/2021 <br /> Q <br /> R ICC Installer's Name Frank Landa Expiration Date 02/28/2021 <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> LSee Attachment With Conditions) q j <br /> A Q OUI <br /> N Plan Reviewers Name 1 a I 90 Date 2, 11 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COLIN Y , ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMAN 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 COMPE SATION LAWS OF CALIFORNIA. " CONTRACTOR 'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PEFO MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA <br /> Permit Clerk 06/24/2019 <br /> Applicant's Signature Title Date <br /> BILLING INF ATION : <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 <br /> Janelle Dockham TITLE Permit Clerk PHONE # 661 -631 -3870 <br /> ADDRESS116250 Meacham Road <br /> 6/24/2019 <br /> SIGNATURE`, DATE <br /> 2 of 6 <br />