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SAN > 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 /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# CAL000477941 Project Contact&Telephone# Ed Garcia 909-709-1266 <br /> A <br /> C Facility Name United#5267 Phone# 209-320-3101 <br /> 1 Address 1137 W Lathrop Rd Manteca CA,95336 <br /> TCross Street N Union Rd <br /> Y Owner/Operator APRO, LLC Phone# (310)323-3992 <br /> o Contractor Name Foxtrot Construction Phone# (951)548-2419 <br /> T Contractor Address 3325 E Shelby St Ontario CA 91764 CA Lic# 1035680 Class B HAZ A <br /> AInsurer Indemnity Insurance Company of North America Work Comp#C72456622 <br /> T ICC Technician's Name Ed Garcia Expiration Date 06/01/2025 <br /> o <br /> R ICC Installer's Name Ed Garcia Expiration Date 06/09/2025 <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 Dispenser 1/2 vapor return line NA Gasoline vapors Unknown <br /> A <br /> N <br /> K <br /> P ❑ Approved &,,Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A //jj,���N Plan Reviewers Name W� /6 Date � � o <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "1 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 Dispatch-Fueling Date 04/11/2025 <br /> L I <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 Emily Lozano TITLE Dispatch PHONE# 951-458-2419 <br /> ADDRESS 3325 E Shelby St/Ontario <br /> CA 91764 <br /> SIGNATURE � ( '�' DATE 04/11/2025 <br /> 2 of 6 <br />