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SAN JOAQUIN Environmental Health Department <br />-COUNTY- <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />y <br />C 0 <br />N <br />T <br />R <br />A <br />C <br />T 0 <br />R <br />T A <br />N <br />K <br />p <br />L <br />A <br />N <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 />D TANK RETROFIT IXPIPING REPAIR/RETROFIT IX UDC REPAIR/RETROFIT [)(COLD START/EVR UPGRADE <br />EPA Site# r.ll.R,ii, ,, 11111 I Project Contact & Telephone# Jesse Diaz <br />Facility Name I ovP.'� Tr::ivP.I �tnn -Rioon <br />Address 1553 Colony Rd, Ripon, CA 95366 <br />Cross Street <br />Owner/Operator Jesse Diaz, Love's <br />Contractor Name Western Pump Inc <br />Contractor Address 3235 F Street San Diego, CA 92102 <br />Insurer Accord <br />ICC Technician's Name <br />ICC Installer's Name Cesar Ibarauen <br />Tank system work area Tank Size (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />See Piping Plan 20,000 <br />See Piping Plan 20,000 <br />See Piping Plan 20,000 <br />See Piping Plan 8,000 <br />See Piping Plan 12,000 <br />Phone# 405-687-1 060 <br />Phone# 405-687-1 060 <br />Phone# 619-239-9988 I CA Lie# 673853 Class A, C10, B <br />Work Comp# CA10003974-201 <br />Expiration Date <br />Expiration Date <br />Chemicals Stored Currently Date UST <br />Installed <br />Diesel 8/21/2001 <br />Diesel 8/21 /2flfl1 <br />Regular Unleaded l:V?1 /?()()1 <br />Regular Unleaded 8/21/2001 <br />Premium Unleaded 8/21/2001 <br />D Approved D Approved with conditions D Disapproved <br />(See Attachment With Conditions) <br />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 HEAL TH 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 />Dlglollj'.,, .. .,,.61-o...._ <br />Greg Mclucas�:_ Title Pro"iect Manaaer 7-19-24Applicant's Signature �1C21.11.2ID1:U:-'OO' Date <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 Jamie Barnes TITLEPermit Administrator PHONE# 479-644-2053 <br />ADDR�S1705 S. Walton Blvd., Ste. 3 Benton, Ar 72712 <br />SIGNATURE <br />� <br />OATE. __ 7_-_1_9_-_2_4 __ _ <br />2 of6