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AN JOAQUIN <br />COUNTY <br />£rlviranme K <br />C rJ LD <br />E� 1 Y �� <br />APPLICATION FOR UNDERGROUND STORAGE TANKAUG UG 1 025 <br />RETROFIT OR PIPING REPAIR PERMIT <br />E N V'oft,GCp?NI1lU9 E N TA t N 1=A LT N <br />7HI$ REKNIT EXPIRES 180 RAYS FROM THE APPRWAL DATE, INDICATE PERMIT TYPE 13EEI�RMITISERV ICES <br />P TANK RETROFJT ❑ PIPING REPAIRJRETROFIT O UIDC REPAIRiRETROFIT Q COLD STARTIJ_VR OPORADE <br />F <br />EPA Site # <br />Project Contact 8 Telephone Man Throkmorton (714) 567-6416 <br />Facility NameAT&T Cali1`omla - UE046 <br />Phone 9 (8i3o) 566-9347 <br />Address 907 Lincoln Rd. Stockton CA_, 95207 <br />Cross Street 2nd Street <br />y <br />OwneliDperator Pacific Bell Telephone Company dba AT&T California <br />Phone #(800) 566-9347 <br />° <br />a <br />Gorltractar Name TAIT Environmental Services Inc_ <br />Phone 9(714) 567-6416 <br />T <br />T <br />CuntracWF Addrew701 N. Parkcenter Dr. Santa Ana CA., 92705 A Lic # 5$8098 Class A HAS <br />AInsurerAAXIS <br />Surplus Irlsu,fance Company <br />Work Comp# 7034385505 <br />T <br />ICC Technician's Name Christopher Bogen <br />IExpirativn Date 0 1 -28-2025 <br />° <br />e <br />ICC Installer's Name <br />Expiration Data <br />Tank system work area <br />Tank Size <br />I Chemical's Stared Currently <br />Gate UST <br />(1A W ptprp wma.1A WOK tea, UUC 10Z etn) <br />installed <br />T <br />SupplylRetum Line Secondary Repair <br />4010 <br />Diesel <br />w-ul-i 99t <br />K <br />I I <br />P <br />I Approved J A0proved with mndltlans ❑ Disavoroved <br />t <br />(See A#tachment Wth Conditions) <br />A <br />Plan Reviewers Name Date 10/3/25 <br />APPLICANT I.IUST PERPOR6A ALL WORii IN ACCORDANCE WITH SAID JOAOIJIN COUNTY ORDINANCK STATE LAU45_ AND RULES AN REGULATIONS OF SAE! <br />OAOUIH COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'r CERTIFY THAT IN <br />TH E PERT" ORMANCE OF TE{E WORK FOR WH ICH THO PER MIT IS ISSUED, I SHALL NOT EMPLOY AN x PEER80N IN SUCH A MAN NER AS TO BECOME SUBJECT To <br />tHER'S COMPENSATION L V4 OF MIFORNK* CONTRACTOR'S HIRING OR SUBCONTRACTING 5IGHATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br />THAT IN T21E PERFORldANGE OF THE WORK FOR VftCH THIS PERMIT I$ 155LIED, I SHALL EMPLOY PER5045 SU$JEGT To WORKER'$ CQMPEN$ATION L*L15 <br />OF CALIFORNIA." EFIp Dravoo� Permit Processor08 -2 -25 <br />Appllranrz $IgMalura imrF %nto <br />BILLING INFORMATION: <br />Indicate the responsible party Io be billed for addilinn PI ERD staff. time. exr—rind beyond permit payment coverage per <br />tank. If tha party designated below is different than the permit applicant, e.g. properly owner, the party must <br />aCkrtowledge this responvizidity for ;hie billing by signature and date below, <br />NAME Ernie Bravo 7I7LE Permit Processor PHONE 0 (2) 27-0072 <br />15012 Zie linde Dr. Lake Elsinore CA., 99-5310 <br />SIGNATURE' DATE0$-2 1 -2025 <br />2 of 6 <br />