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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 ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CAL000286266 Project Contact & Telephone # James Otto 559 -444 - 1730 <br /> � <br /> Facility Name B &W, H & M Food and Liquor Phone # (209 ) 838 - 3971 <br /> L <br /> Address 2501 Jackson Ave , Escalon , CA 95320 <br /> I Cross Street David Drive <br /> T <br /> Y Owner/Operator B &W Phone # 209 -577 -6000 <br /> C Contractor Name LC Services Phone # 559 -444 - 1730 <br /> 0 <br /> N <br /> T Contractor Address 3887 N Valentine Ave , Fresno , CA 93722 CA Lic # 779267 ClassA, B , C10 , C21 , Ha <br /> A Insurer Ace American Insurance Company Work Comp # C69980430 <br /> C <br /> T ICC Technician 's Name Jesus Alvarez Expiration Date 3/ 19/2023 <br /> 0 ICC Installer' s Name p <br /> R 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 /> 87 Drop Tube 121000 RUL 6/1 /1998 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L S Attachment With Conditions ) <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 James Otto Title Project Coordinator Date 2/18/2022 <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 LC Services , James Otto TITLE Project Coordinator PHONE # 559-444- 1730 <br /> ADDRESS 3887 N Valentine Ave , Fresno , CA 93722 <br /> SIGNATURE James Otto DATE 2/18/2022 <br /> 2of6 <br />