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ENVIRONMENTAL HEALTH DEPART <br /> SAN JOAQUIN COUNTY WEIVED <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 FEB 04 2022 <br /> Telephone : (209) 468-3420 Fax : (209) 468 -3433 <br /> ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEP,ARI.MENrEALTi-I <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> Facility Name Harney Lane 76 Phone # 209-518-3496 <br /> L Address 141 E Harney Lane , Lodi <br /> 7 Cross Street South Stockton <br /> 16 <br /> Y Owner/Operator Avin Shaan Investments , LLC Phone # 209-518-3496 <br /> C <br /> 0 Contractor Name BZ Maintenance Phone # 91 &371 -2380 <br /> T Contractor Address PO Box 933 , W Sac CA Lic # see attached Class see attached <br /> R <br /> A Insurer see attached Work comp #see attached <br /> C <br /> T ICC Technician 's Namesee attached Expiration Date <br /> R ICC Installer's Namesee attached Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currents Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDC 1/2, etc.) y Installed <br /> T 87 tank - drop tube 19762 87 <br /> A 91 tank - drop tube 7899 91 <br /> N <br /> K DSL tank - drop tube DSL <br /> P U Approved Approved with conditions J Disapproved <br /> L (See 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 0T <br /> E WO FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATI L OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN E OF 1YIE WORK FOR WHICH THIS PF,RMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WO K 'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> V) <br /> *k �� � <br /> Applicant's Signature Title Dace <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank , If <br /> the party designated below is different than the permit applicant, e.g , property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Avin Shaan Investments , LLC % TITLE PHONE # 209-518-3496 <br /> ADDRESS 5453 Cosumnes Dr. Stockton , CA 95219 <br /> IGNATURE DATE 1 /2222 <br /> EH230038 (revised 12- 11 -15) 2 <br />