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! : CEIV D <br /> Environmental Health epartment <br /> SAN JOAQUIN <br /> -- C o u i\l T Y - --- AUG 1 2022 <br /> APPLICATION FOR UNDERGROUND STORAGLE?OXWNMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # <br /> A Project Contact & Telephone # Janelle Dockham <br /> C Facility Name YRC , Inc . Phone # <br /> 209.833. 1408 <br /> L Address 1535 E . Pescadero Avenue <br /> I Cross Street North McArthur Drive <br /> T <br /> Y Owner/Operator YRCPhone # 209- 833- 1408 <br /> C Contractor Name Nwestco LLC Phone # 661 -631 -3870 <br /> Nr Contractor Address 2209 Zeus Coutt CA Lic # 1073967 Class A Haz <br /> A Insurer Ohio Casualty Insurance Company work comp # XWS57384241 <br /> C ICC Technician's Name Terrence Lay Y Expiration Date <br /> GICC Installer's Name <br /> R Terrence Lav Expiration Date 03/18/23 <br /> Tank system work area Tank Size Chemicals Stored Currents Date UST <br /> p.a. 87 pi&q sump, 91 leak doloclor, UDC 112, ala.) y Installed <br /> T Tank 6 6 , 000 Waste Oil <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> HE 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 /> ORKEWS 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.^ 7 / / <br /> ApplicanrsSignature Dale 08 /15/2022 <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 sign t e and date below, � <br /> NAME 117 IIV��� C r) TITL e6rn 0CAI PHONEC� �' 7L-1( � <br /> 1 (Za) f 4alb <br /> ADDRESS V v' -� W n) <br /> SIGNATURE DATE <br /> 12511 << 07 2 <br /> 2ofs <br />