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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 /> 0 TANK RETROFIT D PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT ©COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Facility Name Fast N Esy#116 Phone# 209-823-3460 <br /> I Address 1399 E. Yosemite Ave. <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# 209-537-9396 <br /> C Contractor Name Donlee Pump Company Phone# 209-537-9396 <br /> 0 <br /> N Contractor Address 2825 Railroad Ave. Ceres, CA. 95307 cA Lic# 432089 Class C61 <br /> T <br /> A Insurer Wausau work Comp# wck-z91-439033-01 <br /> T ICC Technician's Name suis Torres Expiration Date 1/8/17 <br /> D <br /> R ICC Installer's Name Luis Torres Expiration Date 118/17 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC W.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment with Conditions) <br /> N Plan Reviewers Name v CA Date 1 `� <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 SUBJECTTO <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 �,.,Ia2�Z777hO R TdIe 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 2825 <br /> SIGNATURE / G� DATE 6/2912016 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />