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RE W <br /> WW& <br /> ENTAL HEALTH <br /> `1 3 R 2 0 417 SAN JCA UIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 RECEIVED <br /> ENVIRONMENTAL .* ne: (209)485-3420 Fax: (209)468-3433 <br /> !7)EPARTNAENT SEP 2 0 2017 <br /> ,APPLICATION FOR UNDERGROUND STORAGE TANK E RONMENTALNTtl <br /> RETROFIT OR PIPING REPAIR PERMIT PE iTtSEWCES <br /> THIS PERROT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 11 TAW RETROFIT ❑PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> A EPA Site# Prd-4 Contact$Te one# <br /> C Facility Name C + ser 249 401-2378 <br /> Phone'# <br /> L X33 Pacific Avenue,Stockton,CA 95207 <br /> T Cress S ft-2-2-1 <br /> — 01t <br /> YOwn8r/OPsmtOr Edward Marnal <br /> Phone# 916 4 . 3886 <br /> oContractor Name KBISW Commercial Petroleum Phone# <br /> N PO Box 1 ,Linden,GA 9x238 2� 887-2839 t <br /> T CA t is# 859535 Class A <br /> A Insurer Brown&Brown trss Svc of ,PG Box 240,Stockton,CA Work Camp# 1899785-17 <br /> T ICC T 's N e ( i(al tC252318, T ExpirationDate,R ICC lnstalle<s Name Greg Ka ICC#5252318 Expiration Date 04/11!2019 <br /> Tank system work area <br /> Tank Size Date UST <br /> �•� .est ,u sa, i Chemi�ls Stored Currently <br /> Insta <br /> T Tank 3 Tyular Unleaded 10,004 Regular Unleaded lled <br /> A <br /> N <br /> K <br /> t ® Approved Ap with conditions <br /> pproved <br /> A (See Atlachmant With Conditions) <br /> IN Plan RevlaiAws N be <br /> Dal <br /> PUCANT MUST �\ <br /> PERFORM ALL WORKIN ACCORDANCE WITH <br /> LAN IN COU CES,STATE LAW R AND REGULATIONS OF SAN <br /> AL HEALTH DEPARTMENT.OVMER OR LICENSED T8 SIGNATURE TIF THE <br /> E PERFORMANCE THE FOR CH PERMIT IS ISSUED,( NOT EMPLOY ANY : '1 CERTIFY THAT IN <br /> R% 'S HIRING SUBCONTRACTINGIN SUCH A ER AS TO BECOME SUBJECT TO <br /> T LI THE PERFORMANCE H wo WHICH THIS PERMIT ISSUED.1 L EMPLOY PERSONS SUBJECT CERTIFIES CS OOWI NSRTION LAI <br /> CALIFORNIA• l <br /> TiOe Authoria+ed Gant tar Date 9/18/2017 <br /> IndBILLING INFORMATION: <br /> thee party <br /> the to be billed for additional EHD s e be <br /> 19n is different than permit applicant t, e.g. Y0ndPermit ent cover per tank. If <br /> responsibility for the billing by signature and date below. theParty must acknowledge this <br /> NAME Edward Memel <br /> Tln nen PHONE 4LI6148"666 <br /> 3 <br /> ADDRESS PO x 1 CarmiCttaet,CA 95809 <br /> S TUBE 1' <br /> oATE 9,18r2017 <br /> F� c (ftg� ,2, <br /> Y 2 <br /> r <br />