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SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> i <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> N TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Tony Baiady 916 - 261 - 5213 <br /> � Facility Name Chevron # 94275 Phone # ( 209 ) 478 - 5555 <br /> L <br /> Address 2 905 W Benjamin Holt Dr <br /> TCross Street Plymouth Rd <br /> Y Owner/Operator Chevron USA Products Company Phone # <br /> C Contractor Name Wayne Perry Inc . Phone # 916 - 646 - 9680 <br /> 0 <br /> N Contractor Address 30 Main Ave Suite 5 Sacramento , CA 95838 CALic # 300345 Class A , B , HAZ <br /> T <br /> R <br /> A Insurer Everest National Ins . Co Work Comp # CA10003737201 <br /> T ICC Technician's Name Donald Baughn Expiration Date 01 / 11 / 2022 <br /> Q <br /> R ICC Installer's Name Donald Baughn Expiration Date 0 6 / 2 4 / 2 0 2 2 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T 87 Fill Sump 30K Unleaded Gas <br /> A 91 Fill Sump 14K Unleaded Gas <br /> N <br /> K Diesel Fill Sump 6K Diesel <br /> F, ❑ Approved &Approved with conditions El Disapproved <br /> L ment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name �`� 0// ,. elzq <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC 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: N 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 Project Manager Date 03 / 09 / 2021 <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 Anthony Baiady TITLE Project Manager PHONE # 916 - 261 - 5213 <br /> ADDRESS 30 Main Ave Suite 5 Sacramento , CA 95838 <br /> SIGNATURE DATE 03 / 09 / 2021 <br /> 2of6 <br />