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ENVIRONMENTAL HEALTH DEPARTME <br /> SAN JOAQUIN COUNTY RE <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 2 8 2016 <br /> APPLICATION FOR UNDERGROUND STORAGE TAt*VIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> G TANK RETROFIT X PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA_Site# Project Contact&Telephone# 916-224-7280 <br /> � Facility Name PG&E Phone# 916-224-7280 <br /> 1 Address 4040 West Lane Stockton, CA 95204 <br /> L <br /> TCross Street E Alpine Ave <br /> Y Owner/Operator PG&E Phone# 916-224-7280 <br /> C Contractor Name Tait Envoronmental Services Phone# <br /> 0 <br /> N Contractor Address 11280 Trade enter Drive Ranco or ovaCA Lic# Class CIOBAASBH Z <br /> T <br /> A Insurer Barney&Barney,A Mars Mc ennan Ins. Agy LLC Work Comp#UB-3C182680-16 <br /> T John Cascio Expiration Date ° a <br /> ICC Technician's Name C� •� <br /> 0 ICC Installer's Name John Cascio 9/24/2017 <br /> R J 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 <br /> Replacement of Containment Waste Oi <br /> A Boot On Waste Oil Drain <br /> N <br /> K <br /> P U Approved pproved with conditions L1 Disapproved <br /> L (See ttach nt With Conditions) <br /> A �,4 <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 <br /> Project Manager Date 9/21/16 <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 Kristin Brown TITLE Project Manager PHONE# 916-224-7280 <br /> 11280 Trade Center Drive Rancho Cordova, CA 95742 <br /> ADDRESS <br /> SIGNATURE DATE 9/21/16 <br /> EH230038(revised 7-26-2016) 2 <br />