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SA N ,r J O A Q u ( N 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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Christina Tran 408-213-6039 <br /> A <br /> C Facility Name speedway Phone # 209-369-1525 <br /> I Address <br /> L 35 N Cherokee Lane <br /> 1 Cross Street <br /> T Elm St <br /> Y Owner/Operator ,mei Wazer Phone # <br /> C Contractor Name Service Station Systems , Inc Phone # 408-213-6039 <br /> 0 <br /> N <br /> T Contractor Address 680 Quinn Ave CA Lic # 485184 Class B C61 /D40 HAZ <br /> R A Insurer WCF Select Insurance Company Work Com # <br /> 4046603 <br /> T ICC Technician's Name Marcus Garcia Expiration Date 5/12/2025 <br /> RICC Installer's Name 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 /> A <br /> N <br /> K <br /> u <br /> P ❑ Approved �Approved with conditions <br /> Disapproved <br /> L ' ( See Attachment With Conditions) j <br /> N Plan Reviewers Name /tea-- Date <br /> i <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: 1 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 r <br /> OF CALIFORNIA." <br /> Applicant's Signature /�ilS CIG ,4� ) Titre Project and Permit Coordinator Date 4/19/2024 <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 TITLE PHONE # <br /> ADDRESS <br /> SIGNATURE _ DATE <br /> 2 of 6 <br />