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r 3 <br /> JI <br /> �` 4 5 1 <br /> ' ( t( � Environrnent Heli Dbpa')fiiTtent'` <br /> COUNTY- .._._ <br /> t n <br /> LICATION FOR UNDERGROUND STORAGE <br /> APPRETR® FIT OR PIPING REPA R PERMIT TANK <br /> K ' � : ' s <br /> FY6 t r (, C {GIt9 .=. i GI <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209461 -6337 <br /> A <br /> C Facility Name Chevron Phone # 209.832-5006 <br /> I <br /> L Address 3775 Tracy Blvd Tracy Ca 95304 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Debbie Phone # 209-832-5006 <br /> C Contractor Name Megan Mitchell Phone # 209461 -6337 <br /> N <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A-HAZ <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC1033392 <br /> C <br /> T ICC Technician 's Name Expiration Date <br /> R <br /> ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1/2, eta) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved )(Approved with conditions ❑ Disapproved <br /> L e Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date &/Z/ <br /> X� <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 Office Assistant Date 5/13/2020 <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 Megan Mitchell TITLE Office Assistant PHONE # 209461 -6337 <br /> ADDRESS 2535 -7Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE i � �1.(L� DATE 5/13/2020 <br /> 2of6 <br />