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SAN J O A Q U I N Environmental HealtH�epar�me tr I � E Y^ <br /> -- COU NTY `/ p!� <br /> JAN 04 2021 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> ENVIRONMENTAL HEAP <br /> RETROFIT OR PIPING REPAIR PERMIT TII <br /> PERMIT/SERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE . INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ffPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # John Baylis 650- 969 - 9616 <br /> AChevron #60 Stockton Phone # 209-931 -61 54 <br /> C Facility Name <br /> I Address 10878 N Hwy 99 , Stockton , CA 95212 <br /> L <br /> I Cross Street Eight Mile Road <br /> T <br /> Y Owner/Operator Aasim Enterprises Phone # 707486 -8894 <br /> C Contractor Name IEC Services Phone # 650. 969 . 9616 <br /> 0 <br /> N Contractor Address 4901 Warehouse Way, Sacramento , CA 95826 CA Lic # Class <br /> T <br /> A Insurer Insurance Company of West Work comp # WSA5034491 - 04 <br /> T ICC Technician ' s Name Chris Bishop Expiration Date 9/3/2022 <br /> o <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 /> (i .e. 87 piping sump, 91 leak detector, UDC 1 /2, etc. ) Installed <br /> 91 -2 Spill Bucket and Nipple 91 unleaded <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> LSee A hment With Conditions) <br /> A �N Plan Reviewers Name 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 Mgr Date 6/2/21 <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 Mgr PHONE # 650 . 969 . 9616 <br /> ADDRESS 4901 Warehouse Way , Sacramento , CA 95826 <br /> SIGNATURE i1 DATE 6/2/21 <br /> II <br /> I <br /> 2of6 <br /> I <br />