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SANJOAQUIN 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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Monica MOlinar 714-745- 0415 <br /> � <br /> Facility Name Chevron Stations Inc . #94275 Phone # <br /> � Address 2905 West Benjamin Holt Dr . , Stockton , CA 95207 <br /> T Cross Street Plymouth Rd . <br /> Y Owner/Operator Chevron Products Company Phone # 925-842 -9002 <br /> o Contractor Name Wayne Perry Inc . Phone # 714-826-0352 <br /> T Contractor Address 8281 Commonwealth Avenue cALic # 300345 class A , B , HAZ <br /> R <br /> A Insurer Everest Premier Ins , Co . Work comp # CA 10003737221 <br /> T ICC Technician 's Name Glenn Kelley Expiration Date4/ 15/2024 <br /> RICC Installer's Name Expiration Date <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 overfill prevention flapper valve 14 , 000 gal split 91 supreme unleaded 06/ 17/05 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions El Disapproved <br /> L (See 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." g <br /> Applicant's Signature ' " - "O 'Ia� 79eg� Title Project ManagerDate 09/ 12/22 <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 Monica Molinar- West Wind Consultin9ITLE Project Manager PHONE # 714-745 - 0415 <br /> ADDRESS 3334 E . Coast Hwy . , Suite 550 , Corona Del Mar , CA 92625 <br /> SIGNATURE � � DATE 07 . 27 . 22 <br /> 2 of 6 <br />