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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E, Hazelton Ave., Stockton, Califomia 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 REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> CFacility Name Pacific Gas and Electric Company Phone# <br /> I <br /> L Address 4040 West Lane,Stockton <br /> I Cross Street Enterprise Street <br /> T <br /> v Owner/Operator Pacific Gas and Electric Company Phone# <br /> C Contractor Name Tait Environmental Services Phone# <br /> 0 <br /> N Contractor Address 11280 Trade Center Drive,Rancho Cordova,CA 95742 CA Lic# <br /> T 588098 Class A,B,C-10,HAZ <br /> A Insurer Travelers Work Comp# UB3C182680-TIL-14 <br /> T ICC Technician's Name Previously Submitted for SR0072119 Expiration Date <br /> DICC Installers Name <br /> R Previously Submitted for SR0072119 Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> 0.9.eT piping sump.e+task defector,UDC 1,2,atcJ y Installed <br /> T Unleaded Vent Line 10,000 gallon Unleaded Fuel <br /> A diesel Vent Line 10,000 gallon Gasoline <br /> N <br /> K <br /> P ❑ Approved L Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan 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 /> WORKERS COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 /> Applicants SlgnaWre - >' "`'" i4/` Till Re iona]Mana er Dale <br /> / .. . 7129119 <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 Tait Environmental Attn:Jason Musial TITLE Regional Ivian,Ager PHONE# (916)439-2407 <br /> ADDRESS 11280 Trade cEnter Drive Rancho Cordova CA 95742 <br /> SIGNATURE 'r.%r .,✓ DATE 7/29/15 <br /> EH2300381(ievised 07-17-2014) <br /> 2 <br />