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SANJOAQUIN 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 ❑ PIPING REPAIR/RETROFIT ] UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> C Facility Name Shop N Go Phone # 209-952-0001 <br /> I <br /> L Address 4511 Pacific Ave , Stockton , CA 95207 <br /> 1 Cross Street Rosemarie Ln . <br /> T <br /> Y Owner/Operator Ranvir " Ray" Rana Phone # 916-821 -4771 <br /> C Contractor Name IEC Services Phone # 916-993-6312 <br /> 0 <br /> N <br /> r Contractor Address 4901 Warehouse Way, Sacramento , CA 95826 CA Lic # 1064168 Class A, B,C10,C-61 /D40 HAz <br /> R Insurer State Compensation Ins . Fund Work Comp # 9286967-21 <br /> A <br /> T ICC Technician 's Name Brian Lewellen # 10099026 Expiration Date 10/29/23 <br /> R ICC Installer's Name Brian Lewellen # 10099026 Expiration Date 10/29/23 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A No tank changes <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S achment With Conditions) <br /> A <br /> N Plan Reviewers NameDate <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 5/ 19/22 <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 John Baylis TITLE Manager PHONE # 916 . 993 . 6312 <br /> ADDRESS 4901 Warehouse Way , Sacramento , CA 95826 <br /> SIGNATURE �/�' DATE 5/ 19/22 <br /> 2 of 6 <br />