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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 JUL 14 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK - 10HNIEHTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPAR n "47-NT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT NUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# CAD981390073 Project Contact&Telephone# 916-224-7280 <br /> A <br /> C Facility Name Pacific Gas&Electric Phone# <br /> I Address 4040 West Lane,Stockton <br /> L <br /> TCross Street Enterprise St. <br /> Y Owner/Operator Pacific Gas&Electric Phone# 209-561-7163 <br /> C Contractor Name TAIT Environmental Services,Inc Phone# 916-858-1852 <br /> O <br /> N Contractor Address 11280 Trade Center Drive,Rancho Cordova,95742 CA Lic# 588098 Class A,B,C10,HAZ <br /> T <br /> AInsurer See Attached Work Comp# See Attached <br /> TICC Technician's Name See Attached Expiration Date <br /> RICC Installer's Name See Attached Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T Diesel Dispenser Replacement 10,000 gal Diesel <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 Date <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 Title Date <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 /> NAMEKristin Reynolds TITLE Project Manager PHONE#916-669-1852 <br /> ADDRESS 11280 Trade enter Drive,Rancho Cordova,CA 95742 /,, <br /> SIGNATURE _ DATE _IlL <br /> EH230038(revised 7-26-2016) 2 <br />