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SANJOAQUIN 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 X UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> Facility Name Shell Phone# <br /> Address Tracy, <br /> L 3725 Tracy Blvd. y, Ca. <br /> I Cross Street <br /> T <br /> Y Owner/Operator Rebel Corp. Phone# 951-3137490 <br /> o Contractor Name JW's Fuel Services Phone# 559-991-6774 <br /> N T Contractor Address 2711 N. Boise St. Visalia, Ca. 93291 CA Lic# 1069780 Class A <br /> A Insurer Tigner insurance Work Comp# Sole <br /> T ICC Technician's Name Jacob Weaver ICC 8338858 Expiration Date 01/08/2027 <br /> R ICC Installer's Name Jacob Weaver Expiration Date 01/11/2027 <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 87 piping sump Unknown 87 Octane <br /> N All 3+0 UDC's <br /> K <br /> P ❑ Approved X Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A N Plan Reviewers Name Date 5120125 <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 WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Owner Date 5/14/2025 <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 Jacob Weaver TITLE Contractor PHONE# 559-991-6774 <br /> ADDRESS 2711 N. Boise St. Visalia, Ca. 93291 <br /> SIGNATURE /—/ ���� DATE 04/25/2025 <br /> 2 of 6 <br />