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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 /> ❑TANK RETROFIT WIPING REPAIR/RETROFIT C UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 6 Telephone* <br /> � <br /> Facility Name Super Store Phone# 209 858-3384 <br /> � Address 16888 S. McKinley, Lathrop, CA 95330 <br /> TCross Street <br /> Y Owner/Operator Scott Sommerfeld Phone# 209 456-2002 <br /> o Contractor Name Kaiser Commercial Petroleum Phone# (209)401-2379 <br /> T Contractor Address PO Box 1058 Lin n CA 95236CA l c# 8 35 Class A <br /> A Insurer State Compensation Insurance Fund Work Comp# 1839765 <br /> T ICC Technician's Name Greg Kaiser, 5252318 Expiration Dale 04/14/2017 <br /> OR ICC installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (Le Inpwvw .91rr,ae:.aor.UDCV1M) y Installed <br /> T Tank 1 20K Diesel <br /> N Tank 2 20K Diesel <br /> (i KFresh Oil 3 550 Fresh Oil <br /> IWaste Oil 4 550 aste Oil <br /> I I <br /> I _ <br /> PA L Approved i Approved with conditions � Disapproved(See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 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 YAM FOR WH H THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> F CALIFORNIA' 01 <br /> CC � <br /> re Slpnatu 'u �Ttlfe(OCr /i//�5 N[dnd "e M <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 W1 <br /> l'ling by signature and' d//ate below. <br /> J <br /> NAMESCmlh� DJ" 4'je'L W TILE Manager PHONE# (209)456-2002 <br /> /)DDRESS <br /> SIGNATURE DATE IO <br /> ' 'EH230038(revised 10/30/12) <br /> 2 <br />