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SAN JOAQUIN <br />---COUNTY. __.--- <br />Environmental Health Department <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS <br />PERMIT EXPIRES 180 DAYS FROM THE <br />APPROVAL DATE. INDICATE PERMIT TYPE <br />BELOW: <br />TANK RETROFIT l; <br />PIPING REPAIR/RETROFIT <br />UDC REPAIRIRETROFIT COLD <br />START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact &Telephone # Dylan Smith 916-730-7906 <br />A <br />C <br />Facility Name Chevron Station #94275 <br />Phone # <br />I <br />Address 2905 West Benjamin Holt Dr <br />L <br />T <br />Cross Street Plymouth Rd <br />Y <br />Owner/Operator Chevron Products USA <br />Phone # <br />C <br />Contractor Name Wayne Perry Inc <br />Phone # 916-646-9680 <br />0 <br />N <br />Contractor Address 30 Main St, Suite #5, <br />Sacramento CA 95838 <br />CA Lic # 300345 Class see attached <br />T <br />R <br />A <br />Insurer see attached <br />Work Comp # see attached <br />C <br />ICC Technician's Name Nick Harvey <br />Expiration Date 11/20/2024 <br />T <br />R <br />ICC Installer's Name Nick Harvey <br />Expiration Date 8/21/2025 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 plping sump, 91 leak detector, UDC 1121 eta) <br />Installed <br />T <br />91 Fill Sump- Chase Line Penetration <br />Supreme Gasoline 91 <br />A <br />N <br />K <br />P <br />❑ Approved <br />N Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />12/13/24 <br />Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />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 <br />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 />ea �jIt <br />Applicant's <br />Signature <br />Title Project Manager Date 10/1612024 <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_Dylan Smith TITLE Project Manager PHONE # 916-730-7906 <br />ADDRESS_30 Main St. Suite 41 <br />5, Sacramento CA 95838_ <br />s <br />10116!2024 _ <br />