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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 /> 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 # Alan Evans — 562 231 8221 <br /> C Facility Name Chevron 2 017 61 Phone # 2 0 9 825 0174 <br /> 1 Address 1103 S Main St , Manteca CA 95337 <br /> L <br /> TCross Street Mission Ridge Dr <br /> Y Owner/Operator Chevron Products USA Phone # 925 842 1000 <br /> C Contractor Name Wayne Perry Inc Phone # 714 826 0352 <br /> 0 <br /> N T Contractor Address 8281 Commonwealth , Buena Park CALic # 300345 Class A B C10 H Z <br /> A Insurer Milestone Risk Management Work Comp # CA10003737231 <br /> T ICC Technician's Name Nick Harvey #5115738 Expiration Date 10 / 18 /2026 <br /> R ICC Installer's Name Nick Harvey #5115738 Expiration Date 8 /2 2 /2 0 2 5 <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 UDC 1/2 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L Attachment With Conditions) <br /> A ` � 1 <br /> N Plan Reviewers Name Date /� 2 Jr- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCO 9AD! 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 HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORK 'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Project manager f� /j 7,0 <br /> Applicant's Signature Title Date <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 Alan Evans TITLE Project Manager PHONE# 562 231 8221 <br /> ADDRESS 8281 Commo ealth Ave , Buena Park CA 90621el <br /> / <br /> SIGNATURE DATE <br /> 2of6 <br />