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2-k3 <br /> 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 12 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br /> } RETROFIT OR PIPING REPAIR PERMIT HEALTH DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT 0 PIPING REPAIR/RETROFIT O UDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Bonnie Garber 209-537-9396 <br /> C Facility Name Fast N Esy Phone# 209-823-3460 <br /> I Address <br /> L 1399 E.Yoseite Ave. Manteca,CA. <br /> I Cross Street <br /> T <br /> Y Owner/OperatorPhone# <br /> Vikram Vahea' <br /> o Contractor Name Donlee Pump Company Phone# <br /> N Contractor Address 2825 Railroad Ave. Ceres CA Lic# 832089 Class C61/040 HA <br /> T <br /> R <br /> A Insurer Work Comp# <br /> Q ICC Technician's Name Expiration Date 9/30/18 <br /> T Anthony Leivas <br /> R 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 detedo(,UDC 12,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 /> 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 MANNERAS 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 Signator LAG- t TiBe Admin Dace 7/10/2018 <br /> Cl 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 Railroad Ave. Ceres CA. 95307 <br /> SIGNATURE Q JL t_ . a DATE 7/10/2018 <br /> EH230038(revised 12-11-15) 2 <br />