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SANJOAQUIN EnvironmentaRscw - E D <br /> . <br /> COUNTY <br /> FEB 11 2022 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRON DEPARTMENT HEALTH <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 # John Baylis / 650-969-9616 <br /> A <br /> C Facility Name ARCO Cherokee Gas & Mart Phone # 209-224-8925 <br /> 1 Address 900 S Cherokee Lane , Lodi , CA 95240 <br /> L <br /> I Cross Street E Vine St, <br /> T <br /> Y Owner/Operator Karan Pahwa Phone # 916-849-5603 <br /> C Contractor Name IEC Services Phone # 650-969-9616 <br /> O <br /> N Contractor Address 4901 Warehouse Wa Sacramento , CA 95826 CA Lic # 1064168 Class D21 ,C Q /D40, 8, Z <br /> T y . D21 ,C�1 /D40, HAZ <br /> R <br /> A Insurer State Compensation Ins . Fund Work Comp # 9286967-21 <br /> C1 /7/23 Technician 's Name Alex warren Expiration Date 1 /7/23 <br /> T <br /> ICC Installer' s Name p <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> LASee ttachment With Conditions ) <br /> A <br /> 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 2/11 /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 # 650-969-9616 <br /> ADDRESS 4901 Warehouse Way, Sacramento , CA 95826 <br /> SIGNATURE � f DATE 2/11 /22 <br /> 2 of 6 <br />