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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 # Project Contact & Telephone # <br /> A Facility Name AT&T UE020 <br /> C Y Phone # 310 - 997- 5326 <br /> I <br /> L Address 124 West Elm Street, Lodi, 95240 <br /> TCross Street North Church St <br /> Y Owner/Operator AT &T Services Phone # 310 - 997-5326 <br /> C Contractor Name Tait Environmental Services Phone # <br /> 0 <br /> N <br /> T Contractor Address 701 Parkcenter, Santa Ana CA Lic # 580889 Class AHAZ <br /> A Insurer Scott & McCauley Work Comp # SP002747-06 -2023 <br /> T ICC Technician's Name Expiration Date 09/01 /2024 <br /> RICC Installers Name Expiration Date <br /> Tank system work areaTank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T DSL UST 8k DSL Unknown <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A ct <br /> N Plan Reviewers Name c Date2 20 Zq <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." o� � <br /> Applicant's Signature Tti "iO "&eae'" )� Title Project Manager Date 12/28 /2023 <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 parry must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Timothy Mcelheny TITLE project Manager PHONE # 310 - 997 - 5326 <br /> ADDRESS 701 Parkcenter Drive , Santa Ana <br /> SIGNATURE T''"''i° V&! DATE rzlZ�lZ023 <br /> 2of6 <br />