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SANJ O A Q U I N Environmental Health Department <br /> -- COUNTY - - - <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT x UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # John Baylis (650 ) 969 -9616 <br /> A - - <br /> C Facility Name ZOOM Car Wash Phone # (209 )957-9274 <br /> I Address 3434 E . Hammer Lane , Stockton , CA 95212 <br /> L <br /> I Cross Street Holman Rd . <br /> T -- - <br /> Y Owner/Operator Pat Byrne Phone # 916-296 -9959 <br /> C Contractor Name IEC Services Phone # 916-993-6312 <br /> O _ <br /> N Contractor Address 4901 Warehouse Way , Sacramento , CA 95826 CA Lic # 1064168 Class A,e,C10, c61 /D40, nAz <br /> T <br /> R Insurer State Compensation Ins . Fund Work Comp # 9286967-21 <br /> A _ <br /> T <br /> T ICC Technician 's Name Alex Warren Expiration Date 1 /7/23 <br /> Q <br /> R ICC Installer' s Name Gino Balestrieri Expiration Date 2/8/23 <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 /> No work in tank area . <br /> T -- <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ee Att chment With Conditions ) <br /> A � <br /> N Plan Reviewers Name Date_ � ZZ <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 FO <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 Manager Date 11 /5/21 <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 IEC Services/ John Baylis TITLE Manager PHONE # 650 . 969 . 9616 <br /> ADDRESS 4901 Warehouse Way , Sacramento , CA 95826 <br /> SIGNATURE �j""" DATE 11 /5/21 <br /> 2of6 <br />