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To: Elena Manzo Page 3 of 11 2018-08-29 19:10:31 (GMT) 17076380484 From: Nucleus Pump Services <br /> ' Environmental Health Department <br /> RECEIVED <br /> APPLICATION FOR UNDERGROUND STORAGE TANK AUG 2 9 2018 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ENVIRONMENTAL <br /> ANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START QIP{g14ATMFNT <br /> F EPA Site# Project Contact&Telephone# Ronnie Lewis 916/382-4761 <br /> A <br /> c Facility Name Fast and Easy Phone# (209)931-6154 <br /> 1 Address 10878 N. Hwy 99, Stockton, CA 95212 <br /> I Cross Street 99 Frontage Road <br /> T <br /> Y Owner/Operator Asimq Naved Phone# 707/486-8894 <br /> o Contractor Name Nucleus Pump Services Phone# 7081217-4181 <br /> N <br /> T Contractor Address 601 1 st Street, Suite B CA Lic# 949066 Class A—B—D40 <br /> A Insurer Wesco Insurance Company Work Comp# WWC3236024 <br /> T ICC Technician's Name Brian Roth Expiration Date 10/19/2019 <br /> R ICC Installer's Name Brian Roth Expiration Date 10/21/2019 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping eump.81 Mak dotoetor,UDC 1r2,otc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P C Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name_ 1 F uao Date—t-24- x It <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 "1 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,(SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature — Tile Contractor Date 6/411 R <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Ronnie Lewis TITLE Contractor PHONE# 7081217-4181 <br /> ADDRESS 601 1st St., Suite B, Sacramento, CA 95818 <br /> SIGNATUREDATE 6/4/18 <br /> 206 <br />