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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 # Kurt Ramont 916-993-6312 <br /> A <br /> C Facility Name Kesar Petroleum Phone # 408-329-8089 <br /> I Address <br /> L 717 W 8th Street <br /> I Cross Street Manthey Rd <br /> T <br /> Y Owner/Operator Aakash Patel Phone # 408-329-8089 <br /> C Contractor Name Phone # 916-993-6312 <br /> 0 IEC Services <br /> N Contractor Address CA Lic # Class C10 , c-61 /d40 , <br /> T 4901 Warehouse Way 1064168 <br /> AInsurer State Compensation Insurance Fund of California Work Comp # 145250 C <br /> ICC Technician ' s Name Expiration Date 9788 <br /> T <br /> T Brian Lewellan <br /> 0 ICC Installer's Name Expiration Date <br /> R Brian Lewellan P � <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 NO HANGES TO TAN S <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (See At achment With Conditions ) <br /> A <br /> N Plan Reviewers Name CA aO CC X M - lw <br /> Date 31 � �0 a3 <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 , 1 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 CoordinatorDate 3/2/23 <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 Kurt Rarnont TITLE Coordinator PHONE # 916 -993 - 6312 <br /> ADDRESS 4901 Warehouse Way <br /> SIGNATURE /00�1 /. .� DATE 3/2/23 <br /> 2of6 <br />