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SANJOAQUIN Environmental Health Department <br /> - - - COUNTY <br /> - <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 # Victor Hassan / ( 714) 448-5000 <br /> A <br /> C Facility Name H & S Energy #34 Phone # (714) 448-5000 <br /> I <br /> L Address 1434 W Yosemite Ave , Manteca , CA 95337 <br /> 1 Cross Street Watson Ave <br /> T <br /> Y Owner/Operator H & S Energy , LLC Phone # ( 714) 448-5000 <br /> C Contractor Name IEC Services Phone # (916) 993-6312 <br /> O <br /> N <br /> T Contractor Address P O BOX 11160 , Oakdale , CA 95361 CA Lic # 1064168 Class A , B , Haz <br /> R Insurer Work Com # 9286967 <br /> A State Fund p <br /> cICC Technician ' s Name Brian Lewellen Expiration Date <br /> T P 10/29/23 <br /> RICC Installer' s Name Expiration Date <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 Dispenser #1 /2 Relacement N /A <br /> A <br /> N <br /> K <br /> P ❑ Approved NKApproved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �• (ySo Date d `� 130 LO Z <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 /&Mru2 Title Project Manager Date 927/27 <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 Victor Hassan TITLE Vice President PHONE # (714) 448-5000 <br /> ADDRESS 2860 N . Santiago Blvd , Orange Ca . 92867 <br /> SIGNATURE �` ' yyOd°¢'L DATE 9/27/22 <br /> 2 of 6 <br />