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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 />D TANK RETROFIT O PIPING REPAIR/RETROFIT O UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />f=acility Name Fast N Esy #116 <br />Phone # 209-823-3460 <br />I <br />L <br />Address 1399 E. Yosemite Ave. <br />TCross <br />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 />T <br />Contractor Address 2825 Railroad Ave. Ceres, CA. 95307 <br />CA Llc # 432089 Class C61 <br />A <br />Insurer Wausau <br />Work Comp # Wck-z91-439033-01 <br />T <br />ICC Technician's Name Luis Torres <br />Expiration Date 1/8/17 <br />° <br />R <br />t ICC Installers Name Luis Torres <br />Expiration Date 1/8117 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 93 leak detector, UDC 712, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />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 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 />j� <br />ll�J7� Til1e Administrative Assistant Date 6/29/2016 <br />Appllcanl's Si9nalur�,,, l� .lJ _ _ _ h_� l ( <br />q J <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 />ADD <br />6/29/2016 <br />EH230038 (revised 07-37-20 <br />