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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 JUL 16 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TAI�IIVIRONNIENTAL HEALTH <br /> y 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 Fast N Esy Phone# 209-823-3460 <br /> I Address <br /> L 1399 E. Yoseite Ave. Manteca, CA. <br /> TCross Street <br /> Y Owner/Operator Vikram Vohea' Phone# <br /> C Contractor Name Donlee Pum Company Phone# <br /> o <br /> N <br /> T Contractor Address 2825 Railroad Ave. Ceres CA Lic# 432089 Class C61/D40 HA <br /> R <br /> A Insurer Work Comp# <br /> T ICC Technician's Name Expiration Date <br /> T Anthony Leivas P 9/30/18 <br /> Ro ICC Installer's Name Miguel Zaragoza Expiration Date 1/12/2020 <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 (See Attachment With Conditions) <br /> A <br /> Nt Ci - I Qa <br /> Plan Reviewers Name � Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE4VITH 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 Signat' CanTitle Admin Date 7/10/2018 <br /> BILLING INFORMATION.- <br /> Indicate <br /> NFORMATION: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 Railroad Ave. Ceres CA. 95307 <br /> SIGNATURE DATE 7/10/2018 <br /> EH230038(revised 12-11-15) 2 <br />