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S n N.J O n Q U IN <br /> Environmental Health Department <br /> —COUNTY---- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR 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# <br /> A <br /> C Facility Name Western Food & Fuel Phone# <br /> � <br /> Address 3032 Waterloo Rd., Stockton CA 95205 <br /> T Cross Street Sutro Ave <br /> Y Owner/Operator Jay Singh Phone# 916 442-0076 <br /> o Contractor Name Nucleus Pump Services Phone# 916-382-4761 <br /> N <br /> T Contractor Address 601 1st Ave.,Suite B,Sacramento,CA 958181CA Lic# 949066 Class A-B-D40 <br /> A Insurer Wesco Insurance Company work Comp# WWC3236024 <br /> T ICC Technician's Name Brian Roth Expiration Date 10/19/19 <br /> Q ICC Installer's Name Brian Roth Expiration Date 10/19/19 <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved proved with conditions C Disapproved <br /> L (See Attachment With Conditions) <br /> Plan Reviewers NameT,4;t7� Date <br /> APPLICANT MUST PERFORM ALL WO ACCO 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 /> HE 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 Contractor Date 10/17/2018 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME <br /> Ronnie Lewis TITLE Contractor PHONE# 916-382-4761 <br /> ADDRESS 601 1 st Ave.,Suite B,Sacramento,CA 95818 <br /> SIGNATURE ' `— � "�" DATE_ 10/17/2018 <br /> 2 of 6 <br />