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� .Id <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 AUG 9 ZU16 <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 /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan Mitchell <br /> � Facility Name Vanco Truck And Auto Plaza Phone# 209-461-6337 <br /> L Address 1033 W Charter Way <br /> TCross Street <br /> Y Owner/Operator Mike Popari Phone# 916-396-1665 <br /> o Contractor Name Meclan Mitchell Phone# <br /> N Contractor Addressgwam a 95205CA Lie# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casualty Company work comp# BNUWC0133392 <br /> GICC Technician's Name <br /> T Expiration Date <br /> DICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.sT Pipingwmp 91 leak detect«,UDC la,eaJ y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved {p <br /> A proved with conditionss 11Disapproved <br /> L See Attach ent With Conditions) <br /> Q� <br /> N Plan Reviewers Name Date u �3 l6 <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 AGENTS 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 /> WORKERS 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> Applicant's Signatu2 Title Office Assistant Date 8/25/2016 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Megan Mitchell TITLE Office Assistant PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> f'f'L <br /> SIGNATURE Of/IJfi !'//L71�/1� DATE 8/25/2016 <br /> EH230038(revised 12-11-15) 2 <br />