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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209) 468-3420 Fax : (209) 468-3433 <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 /> D TANK RETROFIT D PIPING REPAIRIRETROFIT L?XUDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Bonnie Garber 209-537-9396 <br /> APicone # 209-838-1546 <br /> C Facility Name Escalon Mini Mart <br /> I <br /> L Address 1097 E . Yosemite Ave. Escalon, CA. <br /> TCross Street <br /> Y Owner/Operator Balwinder Singh <br /> Phone # 209-537-9396 <br /> #oContractorameDonlee Pum Company Phone <br /> - <br /> N Contractor Address 2825 Railroad Ave. Ceres CA Lic # 432089 Class <br /> T <br /> R Insurer Work Comp # <br /> A <br /> ICC Technician's Name Jerry Langrell 8899490 Expiration Date 7/23/2022 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 0.a. 87 piping sump, Oi leak detector, UDC 1n1 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 Date <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 Signature Title Admin Dale 11 /11 /21 <br /> 1 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 /> ADDRESS 2825 Railroad Ave. Ceres CA, 95307 <br /> SIGNATURE DATE 11 /11 /21 <br /> EH230038 (revised 12-11 -15) 2 <br /> l <br />