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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 # <br /> A <br /> C Facility Name Arch ARCO Phone # 209-948-2438 <br /> I <br /> L Address 4855 S State Route 99 , Stockton , CA 95215 <br /> 1 Cross Street Arch Road <br /> T <br /> Y Owner/Operator EAGE Investments LLC - Jivtesh Gill Phone # 209-481 -7445 <br /> C Contractor Name LC Services Phone # 559 -444- 1730 <br /> 0 <br /> N <br /> T Contractor Address 3887 N Valentine Ave . Fresno , CA 93722 CA Lic # 779267 Class A, B , CIO , C21 , Ha <br /> R Insurer Ace American Insurance Co . 069980430 <br /> A Work Comp # <br /> C <br /> T ICC Technician 's Name Cliff Woods Expiration Date 3/25/2022 <br /> R ICC Installer' s Name Solomon Untalon Expiration Date 12/30/2022 <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 All dispensers . N/A <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L e ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date Z <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDAN 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 James Otto Title Project Coordinator Date 3/1 /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 James Otto TITLE Project Coordinator PHONE # 559-444 - 1730 <br /> ADDRESS 3887 N Valentine Ave . Fresno , CA 93722 <br /> SIGNATURE James Otto DATE 3/1 /2022 <br /> 2of6 <br />