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ENVIRONMENTAL HEALTH DE• RTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Masood Choudhury (909) 620-5962 <br />A <br />C <br />Facility Name Verizon Manteca CO <br />Phone # (209) 239-0251 <br />I <br />L <br />Address 430 W. Center Street <br />TCross <br />Street <br />Y <br />Owner/OperatorVerizon California, Inc. <br />Phone #(978) 837-3604 <br />o <br />Contractor Name SunWest Engineering Contructors, Inc. <br />Phone # <br />N <br />T <br />Contractor Address 2766 Pomona Blvd <br />CA Lic # 703190 Class A <br />A <br />Insurer Insurance Office of America, Inc, <br />Work Comp # CPCA10998 <br />T <br />ICC Technician's Name Rudy Almazan <br />Expiration Date 04/10/2011 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />Piping vault <br />6,000 -gallon <br />Diesel <br />Unknown <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 />�+ <br />Plan Reviewers Name Date t C -_U ° _ ( 6 <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 <br />TO WORKER'S COMPENSATION LAWS,OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF T f£ WORD FOP WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." t '' <br />Applicant's Signature �� i �_-- Title f/yjfjc441,1 LF_Date v��+ <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />NAME Michael Barber TITLE General Manager PHONE # (909) 594-9850 <br />ADDRESS 2766 Pomona Blvd., Pomona, CA 91768 <br />SIGNATURE DATE <br />EH230038 (revised 07/22/10) <br />2 <br />