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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY REGE <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 l �; <br /> APPLICATION FOR UNDERGROUND STORAGE--!'A%Nr,ii` <br /> RETROFIT OR PIPING REPAIR PERMIT -,ACTH <br /> DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT [DUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Karli Karns(661)631-3870 <br /> A <br /> O Facility Name West Valley Auto Spa Chevron Phone#209-836-3464 <br /> 1 Address 2615 West Grant Line Road <br /> L <br /> TCross Street Naglee Road <br /> Y Owner/OperatorVikas C. Patel Phone#209-836-3464 <br /> C Contractor Name Confidence UST Services, Inc. Phone#(661)631-3870 <br /> O <br /> N Contractor Address 16250 Meacham Road,Bakersfield,CA 93314 CA Lic# 804904 Class Haz A,C61-D40 <br /> T <br /> R <br /> A Insurer State Insurance Fund Work Comp#1308371-2017 <br /> C <br /> T ICC Technician's Name Henryraz Expiration Date 01/25/2019 <br /> �' p <br /> R ICC Installer's Name Frank Landa Expiration Date 11/05/2019 <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 UDC 1/2 <br /> A UDC 3/4 <br /> N <br /> K UDC 5/6 <br /> UDC 7/8 <br /> UDC 9/10 <br /> UDC 11/12 <br /> P ❑ 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 FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature *90dTitle Karli Karns Date 12/07/2017 <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, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Karli Karns TITLE Dispatch Coord.,Confidence UST SvPHONE#(661)631-3870 <br /> ADDRESS 16250 Meacham Road,Bakersfield,CA 93314 <br /> SIGNATURE DATE 12/07/2017 <br /> EH230038(revised 7-26-2016) 2 <br />