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SANJ O A Q U I 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 REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT IN COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> a Stockton <br /> Facility Name Mora 9 Phone# 669-500-3476 <br /> 1 Address 10878 N Hwy 99 <br /> L <br /> TCross Street 99 Frontage Rd <br /> Y Owner/Operator Fast and Easy Phone# <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 /> R A Insurer State Compensation Insurance Fund Work Comp# 1942346-24 <br /> T ]CC Technician's Name Felix Ramirez Expiration Date 8883072 <br /> R ICC Installer's Name Felix Ramirez Expiration Date 8883072 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P F-1 Approved _ Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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 CH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature. 71 Title Office/Business Affairs Manager Date 925-499-6294 <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 Cadacio-Chan TITLE Office/Business Affairs Manager PHONE# 925-499-6294 <br /> ADDRESS P.O.Box 1394, Lafayette,CA 94549 <br /> SIGNATURE DATE <br /> 2of6 <br />