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r <br /> 8 r ' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> ET OFIVOR PIPING REPAIR PERMIT <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# 9168658616 <br /> � Facility Name WATERLOO FOOD & FUEL Phone# 209-466-5618 <br /> 1 Address 3032 WATERLOO RD STOCKTON CA 95205 <br /> L <br /> I Cross Street SUTTRO AND WATERLOO <br /> T <br /> Y Owner/Operator PRITPAL DHILLON Phone# 916-792-6774 <br /> C Contractor Name PINNACLE FUEL COMPLAINCE SVC Phone# 408-206-9840 <br /> T Contractor Address 882 VICEROY WAY CA Lic# Class <br /> AInsurer Work Comp# <br /> T ICC Technician's Name ANIEL CHAND Expiration Date 6/16/2014 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area it Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leek detector,UDC 1/2,etc.) Installed <br /> T INCON TS 1001 10000 MOTOR FUEL <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 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." t <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 WATERLOO FOOD& FUEL TITLE OWNER PHONE# <br /> ADDRESS 3032 WATERLOO RD STOCKTON CA 95205 <br /> SIGNATURE DATE 7/31/2012 <br /> EH230038(revised 08/1/11) <br /> 2 <br />