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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 # Kristin Reynolds 916-224-7280 <br /> A <br /> C Facility Name Pacific Gas & Electric 17 Phone # 209-262-0164 <br /> 1 Address 4040 West Lane , Stockton <br /> L <br /> I Cross Street Enterprise St , <br /> T 209-262-0164 <br /> Y Owner/Operator Pacific Gas & Electric Phone # <br /> C Contractor Name TAIT Environmental Services , Inc . Phone # 916-224-7280 <br /> 0 <br /> N Contractor Address 11280 Trade Center Dr, Rancho Cordova , CA CA Lic # 588098 Class A, 13 , 13- 10 , HAZ <br /> T <br /> R <br /> A Insurer SEE ATTACHED Work Comp # <br /> 0 <br /> r ICC Technician 's Name SEE ATTACHED Expiration Date <br /> 0 <br /> R ICC 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 Overfill Prevention Equipment 1000 Waste Oil 1 / 1 / 1998 <br /> A <br /> N <br /> K <br /> P ❑ Approved XApproved with conditions ❑ Disapproved <br /> L e Attachment With Conditions) <br /> N Plan Reviewers Name Date 12.9� <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 Title Northern CA Director Date 6/22/22 <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 Kistin Reynolds TITLE Northern CA Director PHONE # 916-224-7280 <br /> ADDRESS 11280 Trade Center Drive , Rancho Cordova , CA 95742 <br /> SIGNATURE DATE 6/22/22 <br /> 2of6 <br />