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E <br />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 REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Megan Mitchell 209-461-6337 <br />A <br />C <br />Facility Name Ernies General Store <br />Y Phone # 209-931.2850 <br />I <br />L <br />Address 4407 E Waterloo Rd Stockton Ca 95215 <br />TCross <br />Street <br />Y <br />Owner/Operator ErnestG <br />I Phone# 209-931-2850 <br />D <br />0 <br />Contractor Name Megan Mitchell <br />Phone # 209-461-6337 <br />N <br />r <br />Contractor Address 2535 Wigwam or Stockton Ca 95205 <br />CA Lic # 1001331 Class A-Haz <br />A <br />Insurer Midwest Employers Casualty Company <br />Work Comp # BNUWC0133392 <br />DICC <br />T <br />Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(.e. 87 pipvg sump. sl 19A d"m . UDC 1m akd <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />is chment With Conditions) <br />A <br />N <br />�,.-u`f�� ^ <br />Plan Reviewers Name 1 pikol ' � —db 'djo <br />.<) Date Y T�H� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE Wri SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS 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 />WORKERS 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 tSSUEO, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.- <br />Applicant's Signature T819 Office Assistant Data�— <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. 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 Megan Mitchell TITLE Office Assistant PHONE # 209-461-6337 <br />2535 Wigwam or Stockton Ca 95205 <br />EH230038 (revised 12.11.15) <br />