Laserfiche WebLink
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 /> i <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 1130 DAYS FROM THE APPROVAL DATE . INDICATE PERMIT TYPE BELOW: <br /> Q TANK RETROFIT 0 PIPING REPAIRIRETROFIT I2KUDC REPAIR/RETROFIT O COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Bonnie Garber 209. 537-9396 <br /> Facility Name Escalon Mini Mart Phone # 209-838- 1546 <br /> I Address <br /> L 1097 E . Yosemite Ave . Escalon , CA . <br /> TCross Street <br /> Y Owner/OperatorBalwinder Singh <br /> Phone # 209-537-9396 <br /> o Contractor Name Donlee Pump Company Phone # m53L9396 <br /> N Contractor Address 2825 ' Railroad Ave . Ceres CA Lie /1 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 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I.e. 87 piping sump, 01 leak detector, UDC 1/20 etc) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ ApprovedL�9, Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Pian 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: "1 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 Data 11 /11 /21 <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 /> ADDRESS 2825 Railroad Ave . Ceres CA , 95307 I <br /> SIGNATURE DATE 11 /11 /21 <br /> EH230038 (revised 12-1 i -1 b) 2 <br />