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SAN JOAQUIN Environmelql!e Eck/ E <br /> -- - COUNTY <br /> APR 152021 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: DEPARTMENT <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # FA0003726 Project Contact & Telephone # Ronnie Lewis 916-993-6312 <br /> A <br /> C Facility Name Chevron # 103 Phone # 209-477-2844 <br /> 1 Address 8660 Lower Stockton Rd , Stockton 95210 <br /> L <br /> T Cross Street White Slough <br /> Y Owner/Operator Mike Ali Phone # 925-998-7299 <br /> C Contractor Name IEC Services Phone # 916-993-6312 <br /> 0 <br /> N Contractor Address 4901 Warehouse Way Sacramento 95826 CA Lic # 1064168 ClassA, B , C101 C61 /D40 <br /> T <br /> R <br /> A Insurer Insurance Company of West Work Comp # WSA5034491 -04 <br /> T ICC Technician ' s Name Chris Bishop Expiration Date 11 -3-2023 <br /> 0ICC Installer' s Name Ronnie Lewis Expiration Date 6- 18-2022 <br /> R <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 /> Double Walled 10 , 000 Regular Unleaded <br /> T <br /> A Double Walled 10 , 000 Premium Unleaded <br /> N <br /> K Double Walled 10 , 000 Diesel <br /> P ❑ Approved VApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �� Ir Sy Date I,20 b0 2 <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" D <br /> Applicant's Signature ZOO Title VP of Fueling Date 4/15/2021 <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 IEC Services TITLE PHONE # 916-993-6312 <br /> ADDRESS 4901 Warehouse Way <br /> SIGNATURE � '� DATE 4- 15-2021 <br /> 2 of 6 <br />