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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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> XTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Todd Hansen 909-247-6538 <br /> Facility Name Verizon Lodi CA Phone# 916-205-9291 <br /> L <br /> Address 2500 West Turner Road, Lodi CA 95242 <br /> Cross Street Devries Rd. <br /> T <br /> Y Owner/0perator Dennis Gritsko Phone# 916-205-9291 <br /> o Contractor Name SunWest Engineering Constructors, Inc. Phone# 909-594-9830 <br /> TContractor Address 4780 Cheyenne Way, Chino CA 91710 CA Lic# 703190 Class A, B HAZ <br /> A Insurer Everest Indemnity Insurance Company Work Comp# CPCA17434 <br /> G <br /> T ICC Technician's Name Todd Hansen Expiration Date 11/7/2015 <br /> R ICC Installer's Name Todd Hansen Expiration Date 11/7/2015 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak defector,UDC 112,etc.) Installed <br /> T Diesel 4000 Diesel <br /> A <br /> N <br /> K <br /> P F Approved Approved with conditions ❑ Disapproved <br /> L ( e Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 3 l 1—�y <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN GOUNTY, 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 PERFORM F THE F WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF GALIFORNIA. <br /> Applicant"s Signal re P e a E. Lawwrence Title CEO Date May 5, 2014 <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 arW dat low. <br /> NAME Pamela E. Lawrenc _ CEO PHONE# 909-594-9830 <br /> ADDRESS- 4,780 Ch erne Way, Chino CA 91710 <br /> SIGNATURE DATE May 5, 2014 <br /> EH230038(revised 10130112) <br /> 2 <br />