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SANJOAQUIN Environmental Health Department <br /> --- COUNTY- - <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 /> XTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CERS# 10151123 Project Contact & Telephone # Bill Rogers (760) 743-0518 <br /> C Facility Name Sprint United Management Co . Phone # (217) 9324533 <br /> I Address 3807 Coronado Ave . , Stockton , CA . 95204 <br /> L <br /> TCross Street Enterprise St & E . Fulton St. <br /> Y Owner/Operator Sprint United Management Co . / Ken Carr Phone # 209 937-5800 <br /> oContractor Name Jaure ui & Culver Inc. Phone # 760 743-0518 <br /> N Contractor Address CA Lic # 708231 Class A, B , HAZ <br /> T 959 W. Mission Ave . Escondido CA , 92025 <br /> R Insurer Work Comp # 9040631 - 19 <br /> A Farmer's Insurance <br /> T ICC Technician ' s Name Peter Jauregui III #8195227 Expiration Date 5/29/2021 <br /> T <br /> R ICC Installer' s Name Peter Jauregui III #8195227 Expiration Date 3/29/2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i .e, 87 piping sump, 91 leak detector, UDC 1 /2, etc,) Installed <br /> T Fill Pipe Overfill Prevention Valve Replacement 10 , 000 Gallon Diesel <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) / <br /> N Plan Reviewers Name Date <<I�f v <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." r <br /> Applicant's Si naturefi4 vtzWo2Title President Date <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank . If the <br /> party designated below is different than the permit applicant, e . g . property owner, the party must acknowledge this responsibility <br /> for the billing by signature and date below , <br /> NAME Jaurequi & Culver, inc. / Peter Jauregui TITLE President PHONE # 760-743-0518 <br /> ADDRESS 959 W. Mission Ave . Escondido CA. 92025 <br /> SIGNATURE DATE l� �d .20 <br /> 2of6 <br />