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SAN JOAQUIN 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 /> N TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> C Facility Name Lodi 76 Phone # <br /> I <br /> L Address 1111 E Kettleman Ln , Lodi , CA 95240 <br /> T Cross Street Business Park Dr . <br /> Y Owner/Operator Jivtesh Gill Phone # 209 -481 - 7445 <br /> C Contractor Name LC Services Phone # 559444 - 1730 <br /> 0 <br /> T Contractor Address 3887 N Valentine Ave CA Lic # 779267 ClassA B cto , c2t , Ha <br /> A Insurer Ace American Insurance Co . Work comp # C69980430 <br /> T ICC Technician 's Name Cliff Woods <br /> T Expiration Date 3/25/2022 <br /> 0 <br /> R ICC Installer's Name Soloman 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 Diesel Tank to E85 61000 Diesel <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Dated <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." James Otto <br /> Applicant's Signature Title Project Coordinator Date 3/3/2022 <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 3/3/2022 <br /> 2of6 <br />