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i <br /> ENVIRONMENTAL HEALTH <br /> E PA F�1V1 -r- <br /> SAN <br /> SAN JOAQUIN COUNTY DEC 18 7018 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL HEALTH <br /> DEPARTMENT <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 D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Bonnie Garber 209-537-9396 <br /> APhone# <br /> Facility Name ER Vine Stockton <br /> I <br /> L Address 4733 S. Hwy 99 Frontage Road <br /> I Cross Street Frontage Rd.-Arch Rd. <br /> T - <br /> Y Owner/Operator Richard Erickson Phone# 209-537-9396 <br /> o Contractor Name Donlee Pump Company Phone# 9-F.37-939 <br /> N Contractor Address 2825 Railroad Ave. Ceres CA Li <br /> T C# 432089 Class C61040 HA <br /> — <br /> R Insurer Work Comp# <br /> A -- <br /> T ICC Technician's Name Miguel Zaragoza Expiration Date 1/12/20 <br /> o ICC installer's Name Expiration Date 10/13/19 <br /> R Mario Romero <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (.e.87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See At achment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name �l� `w' Date a� <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,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signaturl Title Admin Dale <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 /> NAME Bonnie Garber TITLE Admin PHONE# 209-537-9396 <br /> ADDRESS28 Railroad Av eres CA. 95307 <br /> SIGNATUR DATE <br /> EH230038(revised 12-11-15) 2 <br />