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ENVIRONMENTAL HEALTH DEPAPITLYMNED <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 DEC 2 2 2016 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE T�1VPC.�Nv <br /> IRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Rick Montesano — 510/614-839 <br /> A <br /> c Facility Name PG&E Stockton Service Center Phone# 209/337-8902 <br /> I Address 4040 West Lane <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Pacific Gas & Electric Phone# 209/337-8902 <br /> o Contractor Name Paradiso Mechanical, Inc. Phone# 510/614-8390 <br /> N Contractor Address 2600 Williams St. , San ;Leandro CA Lic# 677909 Class A B C8 C10 <br /> T C61/D2 <br /> R <br /> A Insurer Work Comp# HAZ <br /> Q ICC Technician's Name Expiration Date <br /> T Greg Geltz No. 5250561—T6chniciari 0610512017 <br /> R ICC Installer's Name Greg Geltz No. 5250561—Installer Expiration Date 02/04/2017 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump.91 leak detector,UDC 1Y2,etc) Installed <br /> T R X R Waste Oil Drain 1,000 gal. WASTE 'OIL 2002 <br /> A Table in Garage <br /> N <br /> K (see Drawings for more Detail) <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> A (S Attachment With Conditions) n <br /> N Plan Reviewers Name Date I l <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." 2 <br /> \ / <br /> Applicant's Signature "• e Project Manager Date 12-21-2016 <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 Eric "Rick Montesano TITLE P. M. PHONE#510/ 614-8390 x 104 <br /> ADDRESS 2600 Williams Street, San Leandro, CA 94577 <br /> SIGNATURE DATE 12-21-2016 <br /> EH230038(revised 7-26-2016) 2 <br />