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SANM O U I N Environmental Health Department <br /> --COUNTY— <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMT EXPIRES 190 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: <br /> O TANK RETROFIT d PIPfNG REPAIRIRETROFIT D UDC REPAIRIRETROFIT Q COLD STARTIM UPGRADE <br /> F EPA Site# Project Contect&Telephone# <br /> A Facility Name AT&T UE020 Phone#310-997-5326 <br /> � .Address 124 west Elm Street,Lodi,95240 — — <br /> I Cross Street North Church St <br /> T <br /> Y Owner/Operator AT&T Services _ Phone# 310-997-5326 <br /> c Contractor Name Tait Environmental Services Phone# <br /> a <br /> T Contractor Address 701 Parkcenter,Santa Ana CA Lic# 580889 Class AHAZ <br /> R insurer Scott&McCaul <br /> " eY Wait Comp# SP002747-06-2023 <br /> C <br /> ICC Technician's Name <br /> T Expiration Dazs 09/01/2024 <br /> a ICC Installer's Name R Expiration Date <br /> Tank system work area Date UST <br /> p,0.07PW19NF�91INkdaredw.UDC 112,dm) Tank Size Chemicals stored Currently Installed <br /> T DSL UST 8k DSI, Unknown <br /> A <br /> N <br /> K <br /> P Approved APProved with conditions L Disapproved <br /> A (S^.3 Attachment IMth Conditions) <br /> N Plan Reviewers Name Date <br /> PPLICANT MUST PERFORM ALL 4WRK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> 'OAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY THAT IN <br /> 1 trE PERFORMANCE OF THE%NORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> W--RKER'S COMPENSATION LAWS OF CAUFORNVI," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO VW)RKER'S COMPENSATION LAWS <br /> 0 F CALIFORNIA," <br /> purer.sbn9rura T^'° } • 7Io� Project Manager _ ote I2l28/2023 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHO 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 data below. <br /> :. Tunathy Mcelheny TITLE ro'ect MqMrr _ HONE# 310-997-5326 <br /> ADDRESS 701 Parkcenter Drive,Santa Ana <br /> SIGNATURE <br /> 2of8 <br />