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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 />a TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name Fast N Esy #116 <br />Phone # 209-823-3460 <br />1 <br />L <br />Address 1399 E. Yosemite Ave, <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # 209-537-9396 <br />o <br />Contractor Name Donlee Pump Company <br />Phone # 209-537-9396 <br />NContractor <br />7 <br />Address 2825 Railroad Ave. Ceres, CA. 95307 <br />CA Lic # 4320$9 Class C61 <br />RInsurer <br />A <br />Wausau <br />Work Co mp # wck-z91-439033-01 <br />ICC Technician's Name Luis Torres <br />Expiration Date 1/$/17 <br />R <br />ICC Installer's Name Luis Torres <br />Expiration Date 1/8/17 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />In stalled <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, eta) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(S ttachment With Conditions) <br />A <br />N <br />n^ `(���� <br />ao <br />Plan Reviewers Name Ult 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicart'sSignature TiEle Administrative Assistant Date 6/2912016 <br />M <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional END staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. properly 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 />SIGNATU <br />EH230038 (revised 07-17-2014) <br />2 <br />6/29/2016 <br />