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SANJ O A Q U I N Environmental Health Department <br /> COU NTY --- <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 XPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> Facility Name Chevron #60 Stockton Phone # <br /> Address 10878 N Hwy 99 , Stockton , CA 95212 <br /> T Cross Street Eight Mile Road <br /> Y Owner/Operator Aasim Enterprises Phone # <br /> C Contractor Name IEC Services Phone # <br /> 0 <br /> N Contractor Address 4901 Warehouse Way , Sacramento , CA 95826 CA Lic # 1064168 Class A, B, C70, C381 C-61/D40 HAZ <br /> T <br /> A Insurer State Compensation Ins . Fund Work Comp # 9286967-21 <br /> T ICC Technician ' s Name Chris Bishop Expiration Date 9/3/2022 <br /> R ICC Installer's Name Chris Bishop Expiration Date 4/20/23 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T 91 Drop Tube 91 Unleaded <br /> A <br /> N <br /> K <br /> P ❑ Approved eeApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date �02 <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 Mgr Date 11 / 1 /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 /> NAME IEC Services / John Baylis TITLE Manager PHONE # 650 . 969 . 9616 <br /> ADDRESS 4901 Warehouse Way , Sacramento , CA 95826 <br /> SIGNATURE DATE 11 / 11 /21 <br /> 2 of 6 <br />