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6401 0IJ <br />ENVIRONMENTAL HEALTH DEPAP-r <br />SAN JOAQUIN COUNTY ffft <br />1868 E. Hazelton Ave., Stockton, California 95205 DEC 19 2011 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TAaVIRONMENTAL HEALTH <br />RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERM)y TYPE BELOW: <br />[]TANK RETROFIT ❑PIPING REPAIRIRETROFIT UDC REPAIR/RETROFIT J?ICOLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Kadi Kams (661) 631-3870 <br />A <br />C <br />Facility Name YRC, Inc. <br />Phone #(209) 833-1408 <br />I <br />L <br />Address 1535 E. Pescadero Ave, Tracy, CA <br />TCross <br />Street North MacArthur Dr. <br />Y <br />Owner/Operator Richard <br />Phone # (209) 833-1408 <br />C <br />O <br />Contractor Name Confidence UST Services, Inc. <br />Phone #(661) 631-3870 <br />N <br />T <br />Contractor Address 16250 Meacham Road, Bakersfield, CA 93314 <br />CA Lic # 804904 Class Haz A, C61 -D40 <br />A <br />Insurer State Insurance Fund <br />Work Comp # 1308371-2016 <br />CICC <br />T <br />Technician's Name Bryan Self <br />rYa <br />Ex Iration Date 0 5/3 012 0 19 <br />P <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 pipelg swop, 91 leak Betecmr, UDC 12, BIG) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />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 AGENTS 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 />Kadi Kams 10/27/2017 <br />ppliceM's Signelure Title Date <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, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Kadi Kams TITLE Agent PHONE # 661-631-3870 <br />16250 Meacham Road, Bakersfield, CA 93314 <br />10/27/2017 <br />EH230038 (revised 7-26-2016) <br />