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SANJOAQUINEnvironmental Health Department <br /> C'`LlNT 'Y' <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EMPIRES i N DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE 88-ow. <br /> o TANK RETROFIT OPUPINGRIEPAWAETROFIT o UDC REPAIRtRETROFIT ❑COLD 3TART/MM UPGRADE <br /> F EPA Site Project Contact 8 Telephone S <br /> 4 A <br /> { C Facility Name Kaiser Permanente Horth Phone# <br /> I Address 7373 West Lane, Stockton, CA <br /> L <br /> TCross Strut <br /> Y Owner/Operator Phone# <br /> o ContratctorName Wilkey's Construction, Inc. Phone# 534-741-2233 <br /> N Skyway Contractor Address 4557 Sk rA Dr. Olivelzuret., CA CAU&#722945 Class A HAZ 5 <br /> T <br /> A Insurer Dick Harris Insurance Agency yvprk CoMp# 3995055472013 <br /> T ICC Technician's Name Jesse Nelson Expiration Date 2-g-20 <br /> o <br /> R ICC InstaWs Name Dale Adams Expiration Date 3-29-19 <br /> Tarn system work area Tank Size Chemicals Stared Cuirentiy Date UST <br /> ti.a e�otgr+I a.�,sr IWt tjoc lM ) 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 Reviwmm Name Hate_ r, (0 f <br /> APPLICANT MusT PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY LACES.STATE LAWS.AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY.ENVIRONMENTAL HEALTH IMPARTMENT.OWNER OR UCEINSED AGENT'S SIGNATURE CER71FIES THE FOLLQIMNG: I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WOW FOR WHICH TWS PERMIT IS[$SUED.i$HALL NOT EMPLOY ANY PERSON IN SUCH A WOMR AS TO BECOME SUWF.CT TO <br /> WORKEWS COMPENSATION L OF CAS H A." CONTRACTOR'S RING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY <br /> THAT IN THE P£ OF THE WORK F IAHCH THIS PERMIT IS ISSUED,I SI ALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Ap can's ntoRwe Ai <br /> BILLING)NFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expanded beyond permit payment/overage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the peony must <br /> admowledge this n*sponsibility for the billing by signature and date below. <br /> NAME WilkeY's Construction. Inc. TITLE COntraet0r PHONED 530-741-2233 <br /> ADDRESS 4 Skyway Dr. Olive st, CA 95951 syr <br /> SIG tfR . DATE <br /> RECEIVED <br /> 2 of 6 <br /> MAR r 2 2018 <br /> ENVIRONMENTAL <br />