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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 # Anthony Romero 916-764-4472 <br /> C Facility Name Chevron #94275 Phone # 209-478-5555 <br /> � Address2905 W Benjamin Holt Dr <br /> TCross Street Plymouth Rd <br /> Y Owner/Operator Chevron USA Products Company Phone # 9116-646-9680 <br /> o Contractor Name Wayne Perry Inc Phone # 916.764.4472 <br /> T Contractor Address 30 Main Ave , Suite 5 , Sacramento , CA 95838 CA Lic # 300345 Class A B HAZ <br /> R <br /> A Insurer Everest National Ins , Co Work Comp # CA10003737221 <br /> T ICC Technician 's Name Brandon Smith Expiration Date 1 /4/2024 <br /> R ICC Installer's Name Brandon Smith Expiration Date 1 /4/2024 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> N Plan Reviewers Name 3,eAA /�- 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 'A kt&gwe Z�)• Azpmog � Title Project Manager Date 10 - 31 -2022 <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 Anthony Romero TITLE Project Manager PHONE # 916 - 764 -4472 <br /> ADDRESS 30 Main Ave , Suite 5 , Sacramento , CA 95838 <br /> SIGNATURE � ilZl�B D' ' ^ M�4 DATE 10 - 31 -2022 <br /> 2of6 <br />