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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 REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name H&M - BW#98 Phone# <br /> I Address 2501 Jackson Ave, Escalon, CA 95320 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Boyett Petroleum Phone# 209-549-5612 <br /> C Contractor Name LC Services Phone# 559-444-1730 <br /> 0 <br /> N Contractor Address 3887 N Valentine Ave CA Lic# 779267 Class A,e,coo,C21 Ha <br /> T <br /> A Insurer Ace American Insurance Company Work Comp# C55561394 <br /> TICC Technician's Name Expiration Date <br /> R ]CC 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 91 Leak Detector 91 Octane <br /> A <br /> N <br /> K <br /> P ❑ Approve Approved with conditions ❑ Disapproved <br /> L ( Nttachment With Conditions) <br /> Arj� <br /> N Plan Reviewers Name Datec% <br /> APPLICANT MUST PERFORM ALL WORK IN CORDAN 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." /m��/ <br /> Applicant's Signature arvve, V. , 'ro Title Project Coordinator Date 2/15/2024 <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 James Otto TITLE Project Coordinator PHONE# 559-444-1730 <br /> ADDRESS 3887 N Valentine Ave. Fresno, CA 93722 <br /> SIGNATURE�Gr7bt O'l'OO'l'O DATE 2/15/2024 <br /> V <br /> 2 of 6 <br />