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ENVIRONMENTAL HEALTH DEPA r- TM,ENT 11 .:. <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 I Fl; 3 7_Qll <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 j <br />APPLICATION FOR UNDERGROUND STORAGE TA.-RWIRONMENTAL HEAum <br />RETROFIT OR PIPING REPAIR PERMIT nFPARTMENT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Bonnie Garber 209-537-9396 <br />A <br />C <br />Facility Name GSG Gas & Mart <br />Phone # 209-993-1298 <br />I <br />L <br />Address 701 E. Dr Martin Luther King Jr Blvd. <br />TCross <br />Street <br />Y <br />Owner/Operator Swaren Chouhan - manager <br />Phone # 209-993-1998 <br />C <br />0 <br />Contractor Name Donlee Pump <br />Phone # <br />909-537-9396 <br />N <br />T <br />Contractor Address 2825 Railroad Ave. Ceres <br />CA Lic # 432089 Class C61 /D40 HA <br />R <br />A <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Name Miguel Zaragoza <br />Expiration Date 8/6/17 <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />li.e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />pproved with conditions ❑ Disapproved <br />❑ Approvedment <br />Xttach <br />LA3 <br />(S With Conditions) <br />N <br />Plan Reviewers Name Date 3r <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 />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 Date <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 />Ave. Ceres. CA. <br />SIGNA <br />EH230038 (revised 12-11-15) V 2 <br />2/3/2017 <br />