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SANJOAQUIN Environmental Health Department <br /> -- COUNTY` -- <br /> APPLICATION <br /> — COUNTYAPPLICATION 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 # <br /> A <br /> C Facility Name ARCO Phone # 209 . 838 , 7579 <br /> 1 Address 1329 Escalon Ave , Escalon 95320 <br /> L <br /> I Cross Street Yosemite <br /> T <br /> Y Owner/Operator Gurpreet Randhawa Phone # (669) 364- 1953 <br /> C Contractor Name IEC Services Phone # (916) 993-6312 <br /> 0 <br /> N Contractor Address 4901 Warehouse Way , Sacramento , CA 95826 CA Lic # 1064168 Class <br /> T D40 HAZ <br /> R <br /> A Insurer Insurance Company of West Work Comp # WSA5034491 -04 <br /> C <br /> r ICC Technician ' s Name Giovanni Balestrieri Expiration Date 1 /12/23 <br /> 0 <br /> R ICC Installer's Name Giovanni Balestrieri Expiration Date 2/8/23 <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 /> No changes to Tanks <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved P Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Named 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 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 Manager Date 8/ 16/21 <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 /> NAMEJOhn Baylis / IEC Services TITLE Manager PHONE # 650 . 969 . 9616 <br /> ADDRESS 4901 Warehouse Way , Sacramento , CA 95826 <br /> SIGNATURE 96;0" DATE 8/ 16/21 <br /> 2of6 <br />