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SANJOAQUIN Environmental Health Department <br /> COU NTY ----- -- <br /> APPLICATION <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 [Z PIPING REPAIR/RETROFIT M UDC REPAIRIRETROFIT [XCOLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Jesse Diaz <br /> Facility Name L v Travel t - Ri n Phone # 405 -687- 1060 <br /> I <br /> L Address1553 Colony Rd , Ripon , CA 95366 <br /> 1 Cross Street <br /> TPhone # 405- 687- 1060 <br /> Y Owner/Operator Jesse Diaz , Love ' s <br /> C Contractor Name Western Pump Inc Phone # 619 -239 - 9988 <br /> T <br /> Contractor Address 3235 F Street San Diego , CA 92102 CA t is # 673853 Class A , C101 <br /> B <br /> R Insurer Accord Work Comp # CA10003974.201 <br /> A <br /> c ICC Technician ' s Name Alex Machado Expiration Date g 3 2022 <br /> T <br /> ° ICC Installer' s Name Expiration Date 11 5 2 0 2 3 <br /> R Cesar Ibar uen <br /> Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) <br /> See Piping Plan 201000 Diesel 8/21 /2001 <br /> T 20 , 000 Diesel <br /> A See Piping Plan 8/21 /2001 <br /> K See Piping Plan 20 , 000 Regular Unleaded 8 /21 /2001 <br /> See Piping Plan 81000 Regular Unleaded 8/21 /2001 <br /> See Piping Plan 121000 Premium Unleaded 8/21 /2001 <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment 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 /> CERTIFY <br /> HORKAT NR'THE PE FORMAINCE OFVTHE WORK FOR IWHI HOT IS PERMIT ISIISSUED ,NG ,II SHALL OEMPLOY IPERSNG ONS SUBJECT TO WORKER'GNATURE CERTIFIES THE S ICOMPENSATION LAWS <br /> OF CALIFORNIA." Greg McLucasTitle Date 11 / 29 / 21 <br /> Project Manager <br /> DW <br /> Applicant's Signature -0^' <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 /> Jamie Barnes TITLE Permit Administrator PHONE <br /> NAME NAME <br /> ADDRESS 1705 S . Walton Blvd . , Ste . 3 Benton , Ar 72712 <br /> � <br /> .,1 720'2022 <br /> DATE ' <br /> SIGNATURE <br /> 2 of 6 <br /> I <br />