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SA N JOAQUIN Environmental Health Department <br /> COUNTY-__. <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> T ERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERM T TYPE BELOW: <br /> TANK RETROFI PIPING REPAIR/RETROFITI:IIJDC REPAIR/RETROFIT DOLD START/EVR UPGRADE <br /> F EPA Site#CAL000436746 Project Contact&Telephone#Cindy Cadacio-Chan, 925-499-6294 <br /> A <br /> C Facility Name Tokay Kwik Sery Phone#209-810-5679 <br /> I L Address420 W. Kettleman Lane., Lodi, CA 95240 <br /> T Cross Street Hutchins St <br /> Y Owner/Operator Jasmine Bains Phone#209-810-5679 <br /> o Contractor Name ECO-CHEK Compliance, Inc. Phone#925-499-6294 <br /> N Contractor Address P.O. Box 1394 CA Lic# 958763 Class A <br /> T <br /> AInsurer State Compensation Insurance Fund Work Comp#1942346-24 <br /> T ICC Technician's Name Marco Alejos Expiration Date 02/28/2027 <br /> R ]CC Installer's Name Marco Alejos 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 Waste Oil Waste Oil <br /> A <br /> N <br /> K <br /> P Approved pproved with conditions [jisapproved <br /> L (See Alaachment With Conditions) <br /> A <br /> N Plan Reviewers Name /C� 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 ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title <br /> Office/Business Affairs Manager Date 9/9/2025 <br /> _ <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 Cindy CadaClO-Chan TITLE Office/Business Affairs Manager PHONE#925-499-6294 <br /> ADDRESS P.O. Box 1394., Lafayette, CA 94549 <br /> SIGNATURE ' DATE 9/9/2025 <br /> 2of6 <br />