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DATE 111912021 * * A M E N D M E N T Permit#S u o 0 s 2 5 s Z!EI Dorado Gas&Mart 1605 S El Dorado,Stockton,CA <br /> RECEIVED <br /> A N. J O A Q U I N Environmental Health Rppa"%e?t2n <br /> -- COUNTY---- <br /> APPLICATION FOR UNDERGROUND STORAGE TAPIRDNMENTAL HEALTH DFPARTMFNT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE INDICATE PERM IT TYPE BELOW <br /> O TANK RETROFIT D PIPING REPAIRIRETROFIT ©UDC REPAIRIRETROFIT D Cl2t.D STA(ii! R U�P,GRADE <br /> F EPA Site# Project Contact&Telephone# v�Maaaa- <br /> .Ud0jj0L2Qq_4r _ <br /> APhone# <br /> C Facility Name - <br /> I Address 1605-S. F-1 Dorado 9t Stockton Ga 95205 <br /> L <br /> I Cross Street • Phone# 510 224-6462 <br /> TPhone# <br /> Y Owner/Operator • Aziz Sher <br /> o Contractor Name I Phone# 209_461_6337 <br /> N Contractor Address 2535 MwwamCA Lie# 001331 ClassA-HAZ <br /> T <br /> A Insurer Midweat EmployerSU01 an Work Comp# <br /> cICC Technician's Name <br /> Expiration Date <br /> T <br /> R <br /> ICC Installer's flame Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> p.e.97prping sump,Bt leek daiwar.UbC 112.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date7i0 <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 /> 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" CONT R'5 HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: N CERTIFY <br /> 51ndicatelheregsponsi <br /> FORMANCE OF THE WORK FOR WHI THIS PE MIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> CALIFORNIA.' <br /> re Title Date <br /> TEG INFORMATION: <br /> sponsib party to be billed for additional EH 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 /> acknowiedge this responsibility for the billing by signature and date below. <br /> NAM EDeborah Jones TITLE_fGCe A SLStant PHONE#?n4_ -6237 <br /> ADDRESS <br /> SIGNATU E DATE 9/1/2()9n <br /> 2 of 6 <br />