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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: 1 <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/ RETROFIT UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE ! <br /> F EPA Site # Project Contact & Telephone # Bonnie Garber 209-537-9396 <br /> C Facility Name Escalon Minl Mart Pllone # 209-838-1546 <br /> I <br /> L Address 1097 E . Yosemite Ave. Escalon, CA , <br /> TCross Street <br /> Phone # 209-537-9396Y Owner/OperatorSinghBaiwinder <br /> o Contractor Name Donlee Pump Company Phone # 909-537m919171 <br /> N Contractor Address 2825 Railroad Ave. Ceres CA Lie # 432089 Class <br /> T <br /> R <br /> A Insurer Work Comp # <br /> T 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 /> (te. 87 plptng sump, 81 leak detector, UDC 12, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> I <br /> P ❑ Approved I Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> 2 <br /> N Plan Reviewers Name Date 2,02LI <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 1S ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> App!icant'sSignature "� Ti11e I Date 11 /1 2 <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. 96307 <br /> I <br /> SIGNATURE DATE 11 /11 /21 <br /> EH230038 (revised 12-11 - 15) 2 <br /> I <br />