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• • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, Cal'Ifomia 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 ❑PIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name Pacific Gas and Electric Company Phone# <br /> I <br /> L Address 4040 West Lane,Stockton <br /> TCross Street Enterprise Street — <br /> Y Owner/Operator Pacific Gas and Electric Company Phone# <br /> D Contractor Name Tait Environmental Services Phone# <br /> 0 <br /> " Contractor address 11280 Trade Center Drive CA Lic# 588098 Class A,B,C-10,11 Z <br /> T <br /> R Insurer Travelers Work Comp#UB3C182680-TIL-14 <br /> A <br /> C <br /> T ICC Technician's Name Attached Expiration Date <br /> o <br /> R ICC Installer's Name Attached Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.eI plpkV sump,01 leak doledor,UDC 12,etc.) Installed <br /> T Unleaded vent line 10,000 gallon Unleaded <br /> A Diesel Vent Line 10 000 allon Diesel <br /> N <br /> K <br /> P ❑ Approved pproved with conditions IJ Disapproved <br /> L (S a Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 7 <br /> APPLICANT MUST PERFORM ALL WORK IN dfCcORDANCE 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 /> 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 IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> APPlicanfs Signature ^�' ' ''T'' ` T18e Re Ronal Manager <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional Ei 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 Manager PHONE# (916)439-2407 <br /> ADDRESS 11280 Trade Center Drive Rancho Cordova Ca 95742 <br /> J 7-7-15 <br /> SIGNATURE DATE <br /> E11230038,0vised 07-17-2014) <br /> 2 <br />