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DATE 111$12021 * * A M E N D M R N T Permit#s R O 0 8 2 5 9 2 1 El Dorado Gas a Mart 1605 S Ef Dorado,Stockton,CA <br /> RECEIVED <br /> (` N, 1 O /► (I IN <br /> IV Environtnental Health.�pagny2�120 <br /> �} <br /> COUNTY <br /> uU----- <br /> QVIRONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TADEPARTMENT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 980 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW. <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT 12CQ VR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> Facility Name Phone# 209_939_1 906 <br /> I Address 1605 S El Dorado St StorktQn Ca 95205 <br /> L <br /> I Cross Street • Phone# 510224-6462 <br /> T <br /> Y Owner/Operator 0 AZIZ Sher Phone# ,--- <br /> o Contractor Name J phone# 209-461-6337 <br /> N Contractor Address GA Lic# <br /> T 1001331 Class <br /> A Insurer Midwest E 10 el'C S I an Work Gomp# <br /> o <br /> r IGC Technician's Name Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> p.e.B7 piping sump,01 leak detecWr,UDC V2.elc.1 Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A NPlan Reviewers Name Date (731212,0 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; "I CERTIFY THAT IN <br /> HE 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." COT R'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIE=S THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHI THIS PE MIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Dat91112020 <br /> e <br /> ING INFORMATION: <br /> Indicate the reapon ib 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 <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME_,,,,.,., DebOrah JtOneS_TITLE Offlrp Assistant PHONE# 209- 61_62 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca-952051 <br /> SIGNATU E DATE 4/1/2020 <br /> 1/ I7I"Wl t <br /> 2 ors <br /> I <br /> I <br />