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SANJOAQUIN Environmental Health Department <br /> -- - COUNTY - <br /> APPLICATION <br /> - COUNTY - 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 /> 5d 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 Tracy Market Phone # 209-676-0916 <br /> I <br /> L Address 15 E . Grant Line Rd . <br /> T Cross Street Holly Dr <br /> Y Owner/Operator Harpreet Singh Phone # 209-676-0916 <br /> C Contractor Name ECO-CHEK Compliance , Inc. Phone # 925-499-6294 <br /> 0 <br /> N Contractor Address P . O . Box 1394 <br /> T CA Lic # 958763 Class A <br /> A Insurer Work Comp # 1942346-23 <br /> C Expiration Date 03/17/2025 ICC Technician 's Name Marco Ale os Ex <br /> T 1 p <br /> 0ICC Installer' s Name Marco Ale os Expiration Date <br /> R 1 p 07/22/2025 <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved {� Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> A II <br /> N Plan Reviewers Name Date <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 F H THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER 'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Compliance Operations Associate Date 02/01 /2024 <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 Cindy Cadacio-Chan TITLE Compliance Operations Associate PHONE # 925-499-6294 <br /> ADDRESS P .O . Box 1394 . , Lafayette CA 94549 <br /> SIGNATURE DATE 02/01 /2024 <br /> 2 of 6 <br />