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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 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 # James Otto (559) 444 - 1730 <br /> � Facility Name Charter Way Chevron Phone # <br /> I <br /> L Address508 Dr . Martin Luther King Jr . Blvd , Stockton , CA 95206 <br /> TCross Streets . Lincoln St , <br /> Y Owner/Operator Phone # <br /> C Contractor Name LC Services Phone # 559 -444- 1730 <br /> 0 <br /> NCA Address 3887 N Valentine Ave , Fresno , CA 93722 CA Lic # 779267 class A, e, cio, c21 , HAZ <br /> T <br /> A InsurerACE American Insurance Company Work Comp # C66373551 <br /> c <br /> T ICC Technician 's Name Clifton Woods Expiration Date 12/30/2022 <br /> 0 <br /> R ICC Installer's Name Solomon Untalon Expiration Date 9/9/2022 <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 UDC 5/6 <br /> A UDC 7/8 <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A achment With Conditions) <br /> A II __ i , I <br /> N Plan Reviewers Name Date ©KJ � �l <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 Project Coordinator Date 4/7/2021 <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 LC Services TITLE James Otto (Project Coordinator) PHONE # 559 -444 - 1730 <br /> ADDRESS 3887 N Valentine Ave , Fresno , CA 93722 <br /> SIGNATURE DATE 4/7/2021 <br /> 2of6 <br />