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ENVIRONMENTAL HEALTH DEP TT. Ej_1 ,V,� � <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 J A i l {t �; 1.01tt <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGEf�X&ONIMENTAL, HEALT-H <br /> RETROFIT OR PIPING REPAIR PERMIT M-T'An T MEW <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Me an 209-461-6337 <br /> c Facility Name Vanco Phone# 916-396-166,11_5 <br /> I Address 1033 W Charter Way Stockton Ca 95205 <br /> L <br /> I Cross Street <br /> T <br /> Y OwnerlOperator Mike Popari Phone# 916-396-160 <br /> cContractor Name Phone# 209-461-6337 <br /> 0 <br /> N Contractor Address <br /> T CA Lic# 100331 Class <br /> A Insurermidwest Employers CasualtyCompanywork comp# gNUWC0133392 <br /> C <br /> r ICC Technician's Name Expiration Date <br /> D <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 0.e.87 piping sump,91 leak detoclor.UDC 112,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 <br /> N Plan Reviewers Name �'� I`�ar�a� Date I/ /�$ <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 FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applicant's Signature Me aK Mitchea nue Offiee-AssiS.tant_. Dale <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 Offire Assistant PHONE# 209-461_6337 <br /> ADDRESS_253Wiawam Dr Stockton Ca 95205 <br /> SIGNATURE Meats Mitcheg DATE 41A.1.911 n <br /> EH230038(revised 12-11-15) 2 <br />