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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 N COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> APhone # 209-224-8925 <br /> C Facility Name Cherokee Arco <br /> 1 Address <br /> L 900 S . Cherokee Ln . Lodi CA. 95240 <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 # 916 . 993 . 6312 <br /> 0 <br /> N Contractor Address CA Lic # 1064168 Class A, B , C-61 /D401 <br /> T 4901 Warehouse Way, Sacramento , CA 95826HA <br /> R Insurer State Compensation Ins . Fund Work Com # <br /> A p p 9286967-21 <br /> T ICC Technician 's Name Expiration Date <br /> T Chris Bishop P 9-2-22 <br /> 0 <br /> R ICC 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 1 /2, etc.) Installed <br /> T <br /> A r <br /> N <br /> K <br /> P ❑ Approved Approved with conditions El Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 4 AA Date �5l �� <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 7/8/22 <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 Jahn RaVlis TITLE Manager PHONE # ('i50 . 9F9 . 9F1F <br /> ADDRESS 4901 Warehouse Way , Sacramento , CA 95826 <br /> SIGNATUREDATE 7 /8/22 <br /> 2of6 <br />