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S A N JOAQUIN <br /> O nHQ I V I I N Environmental Health Department <br /> f-1C0UNTY ' i <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 /> N TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Zachary Feingold (909) 879-2712 <br /> A <br /> C Facility Name Mid City Ca FO Regen 717 <br /> Phone # (909 ) 879-2712 <br /> I <br /> L Address 13850 Devries Road <br /> I Cross Street <br /> T <br /> Y Owner/Operator Verizon Business Purchasing , LLC Phone # (909 ) 879-2712 <br /> oContractor Name SunWest Engineering Constructors , Inc. Phone # (888) 588-8737 <br /> N Contractor Address 4780 Cheyenne Way CA Lic # 703190 Class A , B , Haz <br /> T <br /> R <br /> A Insurer State Compensation Insurance Fund of CA Work Comp # 9243819-20 <br /> C <br /> T ICC Technician 's Name Todd Hansen Expiration Date 10/4/2023 <br /> R <br /> ICC Installer's Name Todd Hansen Expiration Date 10/4/2023 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i. e. 87 piping sunp, 91 leak detector, UDC 1122 etc.) Installed <br /> T Piping Sump 550 gallon Diesel <br /> A <br /> N <br /> K <br /> P �_.� Approved Approved with conditions Disapproved <br /> L ( 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 SignatureLzvtlo\� Title Project Manager Date 10/ 19/21 <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 Vanessa Ortega TITLE Project Manager PHONE # (909 ) 536 -6458 <br /> ADDRESS 4780 Cheyenne Way , Chino , CA 91710 <br /> SIGNATURES DATE 10/ 19/21 <br /> 2of6 <br />