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A : 1 Q U 1 Environmental Health Department <br /> C o U N T Y__v_ <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> T RMIT EXPIRES 180 DAYS FROM �QPPROVAL DATE. INDICATE P TYPE BELOW: <br /> DANK RETROFIIt/JIPING REPAIR/RETROFIT PDC REPAIR/RETROFITL.FOLD STARTIEVR UPGRADE <br /> F EPA Site # CAL000200529 Project Contact & Telephone # Chris Buscaglia 209-956-4040 <br /> A <br /> c Facility Name California Car Wash Phone #209-956-4040 <br /> I <br /> L Address 3434 E Hammer Lane <br /> T Cross StreetHolman <br /> Y Owner/Operator California Car Wash Phone # 209-957-9274 <br /> C Contractor Name AFFORDA TEST Phone # 209-744-0112 <br /> 0 <br /> T Contractor Address 416 2nd Street CA Lic # 341375 Class C36 <br /> A Insurer State Fund Work Comp # 1916583-2021 <br /> T IGC Technician's Name Zane Nimmo Expiration Date 05/26/23 <br /> R ICC Installer's Name Zane Nimmo Expiration Date 05/26/23 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC M/ etc.) Installed <br /> T 87 fill drop tube 12 , 000 87 gasoline 08/ 1989 <br /> A 91 fill drop tube 6 . 000 91 gasoline 08/ 1989 <br /> N <br /> K diesel fill drop tube 61000 diesel 08/1989 <br /> P Approved Approved with conditions disapproved <br /> L e ' A achment With Conditions ) <br /> A ( r� <br /> N Plan Reviewers Name ( Date GU <br /> APPLICANT MUST PERFORM ALL WORK INC DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WO ERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATIO S OF CALIFORNIA," NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFOR CE OF THE WORK FOR WHIC THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant's Signature I Title G MNP Date 10/02/2021 <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 /> NAM Ls3'Q1 TITLE PHONE # r [n <br /> ADDRESS S4 S4 F _ M t rl Z <br /> SIGNATURE DATE , + <br /> Li <br /> 2of6 <br />