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y���351H <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, Califomia 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 190 DAYS FROM THE APPROVAL DATE INDICATE PERMF TYPE BELOW. <br />OTANK RETROFIT OWING REPAIR/RETROFIT ElUDC REPAIR/RETROFIT MICOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact 8 Telephone # Kadl Karns (661) 631-3870 <br />CFacility <br />Name YRC, Inc. <br />Phone#(209)833-1409 <br />I <br />L <br />Address 1535 E. Pascadero Ave, Tracy, CA <br />TCross <br />Street North MacArthur Dr. <br />Y <br />Owner/Operator Richard <br />Phone # (209) 833-1408 <br />0 <br />D <br />Contractor Name Confidence LIST Services, Inc. <br />Phone # (661) 631-3870 <br />N <br />T <br />Contractor Address 16250 Meacham Road, Bakersfield, CA 93314 CA LIC #804904 Class Haz A, C61 -D40 <br />R <br />A <br />InsurerState Insurance Fund <br />Work Comp # 1308371-2016 <br />T <br />ICC Technician's NameBryan Self <br />Expiration Date 05/30/2019 <br />DR <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size Chemicals Stored Currently <br />Date UST <br />an. 97 pipirp num, 91 leak O Wl r, UDC 12, a1a) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved <br />Approved with conditions v <br />L <br />Se Attachment W th Conditions) rV <br />A <br />N <br />Plan Reviewers Name <br />1 1 17 11111, <br />Date <br />IV <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. <br />OWNER OR LICENSED AGENTS SIGNA=,p?�THE.FO OWING: `I CERTIFY THAT IN <br />HE PERFORMANCE <br />OF THE WORK FOR WHICH THIS PERMIT <br />IS ISSUED, I SHALL NOT EMPLOY ANY P 1IUU iiMMAAIN A.$,'Ig COME6p9JECT TO <br />WORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWI CERTIFY <br />THAT IN THE PERFORMANCE O THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." / / <br />// Kalli Karns <br />Ap~s Signature <br />.title -Date10/27/2017 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, a.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Kadl Karns TITLE Agent PHONE 0 681-831-3870 <br />16280 Meacham Road, Bakersfield, CA 93314 <br />10/27/2017 <br />EH230038 (revised 7-26-2018) <br />