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SANJOAQUIN Environmental Health Department <br /> - <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 /> TANK RETROFIT ❑ PIPING REPAIR/ RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Tony Baiady <br /> y Chevron # 94275 <br /> Facilit Name Phone # ( 2 0 9 ) 478 - 5555 <br /> I Address 2905 West Benjamin Holt Dr <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Chevron Products USA Phone # <br /> C Contractor Name Wayne Perry Inc Phone # 916 - 646 - 9680 <br /> O <br /> N Contractor Address 30 Main Ave CA Lic # 300345 Class A C 2 C3 <br /> T <br /> R <br /> Insurer Vs �34& Work Comp # ( A I0W 3737 1 q <br /> T ICC Technician 's Name Donald Baughn Expiration Date <br /> R ICC Installer' s Name Donald Baughn Expiration Date 2 q12 2 <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 <br /> 87 Turbine Sump 36K aN5o (' <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se 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 itle_Project Manager Date_ 09 / 28 / 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—Tony Baiady TITLE_Project Manager_PHONE # 916 - 646 - 9680 <br /> ADDRESS 30 Main Ave Suite 5 Sacramento , CA 95838 <br /> SIGNATURE DATE <br /> 09 / 28 / 2020 <br /> 2 of 6 <br />