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1 <br /> ENVIRONMENTAL HEALTH DEPA TMENT , tD <br /> Q <br /> SAN JOAQUIN COUNTY � -!' a , �' <br /> 1868 E. Hazelton Ave., Stockton, California 95205 FEB 13 2017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE T /IRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Bonnie Garber 209-537-9396 <br /> A <br /> C Facility Name GSG Gas & Mart Phone# 209-993-1298 <br /> I Address <br /> L 701 E. Dr Martin Luther King Jr Blvd. <br /> TCross Street <br /> Y Owner/Operator Swaren Chouhan-manager Phone# <br /> C Contractor Name Phone# <br /> O Donlee Pum Com an <br /> N Contractor Address 2825 Railroad Ave. Ceres CA Lic# 432089 Class C61/D40 HA <br /> T <br /> R <br /> A Insurer Work Comp# <br /> C ICC Technician's Name Expiration Date <br /> T Miguel Zaragoza P� 8/6/17 <br /> RCC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S e Attachment With Conditions) <br /> A 3 3� <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 DEPAR i MENT. 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 /> 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 WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Admin Date 2/3/2017 <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 Bonnie Garber TITLE Admin PHONE# 209-537-9396 <br /> ADDRESS 2825 RA'Iroad Ave. Ceres CA. 95307 <br /> SIGNATURE DATE 2/3/2017 <br /> EH230038(revised 12-11-15) 2 <br />