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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 190 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br /> TANK RETROFIT WIPING REPAIRIRETROFIT - UDC REPAIR/RETROFIT C COLD STARTIEVR UPGRADE <br /> F EPA Site# Projerl Contact&Telephone# <br /> A Facility Name _Super Store Phone# (209)858-33_84 <br /> L Address 16888 S. McKinley, Lathrop, CA 95330 <br /> Tcross Street <br /> Y Owner/Operator Scott Sommerfeld Prone# 209 456-2002 <br /> C Contractor Name _ Kaiser Commercial Petroleum <br /> 0ne# 209 401-2379 <br /> T" Contractor Address PO Box 1058 Linden CA 9 23 CALX# 859535 Class A <br /> Insurer State Compensation Insurance Fund Work Comp# 1839765 <br /> T ICC Technicians Name quegl Kaiser 5252318_- Expiration Date 04114/2017 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemlcels Stored currently Date UST <br /> p.a./r c7ptp wn+n.s7lnnarco,uoc lrz�7 Y InstaCed <br /> T Tank 1 20KI Diesel <br /> N Tank 2 OK Diesel <br /> KFresh Oil 3 550 <br /> Fresh Oil <br /> Waste Oil Waste Oil <br /> L _. Approved Approved with conditions Disapproved ---� <br /> A (See Attachment With Conditions) / <br /> N Plan Reviewers Name rs�� Date /0 ! Z) / d <br /> iAPPUCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> IJOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> 1717E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SRALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAMS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING '1 CERTIFY <br /> TIN THE PERFORMANCE OF THE WORK FOR THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> jQF CALIFORNIA' <br /> 1'\AJ\IyA"� res gnam�a�✓.ff/ �.P./ rnh J7cr/i/f1S IVLananl�Irib �V '/Z '" ��j <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, eg property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below <br /> NAM�� _JD�rI rvr�(r�_ -* TrrLE Manager PHONEY (2091456-2002 <br /> ADDRESS f <br /> .. SIGNATURE_ <br /> ` H230035(mYised 70/30/12) <br /> 2 <br />