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SAN _ 11 O A Q U I N Environment�6IF40 t9AyP hfi�fit <br /> -- COUNTY JUN 04 20'23 <br /> APPLICATION FOR UNDERGROUND STORAGF� tNTAli ISNINIENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT I) rt>AIZTNICNT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT XPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # FA0003726 Project Contact & Telephone # John Baylis 916 . 993 . 6312 <br /> C Facility Name Chevron # 103 Phone # 209-477-2844 <br /> 1 Address 8660 Lower Stockton Rd , Stockton 95210 <br /> L <br /> T Cross StreetWhite Slough <br /> Y Owner/Operator Mike Ali Phone # 925 - 998- 7299 <br /> C Contractor Name IEC Services Phone # 91 & 993-6312 <br /> O <br /> N Contractor Address 4901 Warehouse Way, Sacramento , CA 95826 CA Lic # 1064168 Class A,B,C10,C61 /D40 HAZ <br /> T <br /> A Insurer Insurance Company of West Work Comp # WSA5034491 - 04 <br /> T ICC Technician 's Name Chris Bishop Expiration Date 9-2-22 <br /> R ICC Installer's Name Chris Bishop Expiration Date 4-20 - 21 <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 91 Fill drop tube & nipple 91 unleaded <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( eq <br /> ttachment 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 Title Mgr Date 6/4/21 <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 John Baylis TITLE Mgr PHONE # 916 - 993 -6312 <br /> ADDRESS 4901 Warehouse Way , Sacramento , CA 95826 <br /> SIGNATURE qLA DATE 6/4/21 <br /> 2 of 6 <br />