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so <br /> 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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name Fast N Esy#116 Phone# 209-823-3460 <br /> L <br /> Address 1399 E. Yosemite Ave. <br /> TCross Street <br /> Y Owner/Operator Phone# 209-537-9396 <br /> o Contractor Name Donlee Pump Company Phone# 209-537-9396 <br /> T Contractor Address 2825 Railroad Ave. Ceres, CA. 95307 CA Lic# 432089 class C61 <br /> R <br /> A Insurer Wausau Work Comp# Wck-z91-439033-01 <br /> T ICC Technician's Name LUIS Torres Expiration Date 1/8/17 <br /> R lCC installers Name Luis Torres Expiration Date 1/8/17 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le.87 piping sump,91 leak detector,UDC 112,eta) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A tachment With Conditions) <br /> A AMNPlan Reviewers Name gwa � Date F �� <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 AGENTS 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 Signatur Title Administrative Assistant Date 6/29/2016 <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 /> NAMEBonnie Garber TITLE Admin. Asst. PHONE# 209-537-9396 <br /> ADDRESS <br /> SIGNATURE DATE 6/29/2016 <br /> EH230038(revised 07-117-2014 <br /> 2 <br />