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SANJOAQUIN Environmental Health Department <br /> - - COU NTY - <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 /> � Address 2501 Jackson Ave , Escalon , CA 95320 <br /> 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 <br /> T Contractor Address 3887 N Valentine Ave CA Lic # 779267 Class A, B , C1 o , C21 Ha <br /> A Insurer Ace American Insurance Company Work Comp # C55561394 <br /> TICC Technician ' s Name Expiration Date <br /> RICC 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 ( attachment With Conditions) <br /> A <br /> N Plan Reviewers Name A Date <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." �/ <br /> Applicant's Signature axrvve/ge 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 # 559444 - 1730 <br /> ADDRESS 3887 N Valentine Ave . Fresno , CA 93722 <br /> SIGNATURE�Gr7bt P/,1' V'f ' OV'f ' O DATE 2/ 15/2024 <br /> V <br /> 2 of 6 <br />