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SAKJOAOUINEnvironmental Health Department <br /> CC1LlNTv <br /> APPUCATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW. <br /> ❑TANK RETROFIT ❑P9WG REPAIRIRETROFFT D URC REPAIRMETROFIT O COLD STARTIEVR UPGRADE <br /> F EPA Site ff Project Contact&Telephone* <br /> CFacility Name: Kaiser Permanente North Phone# <br /> 1Address 7373 West Lane, Stockton, CA <br /> L <br /> T Cross Stmt <br /> Y Owner/Operator Phone# <br /> o Con Name Wilkey's Construction, Inc. Phone# 530-741-2233 <br /> T ContradwAddress 4557 Skyway Ar, Oli.vehurst, CA CA Lle#722945 ,lass A HAZ B <br /> A Insurer Dick Harris Insurance Agency MrkC=p# 3995065472013 <br /> T ICC Technician's Name Jesse Nelson ExPiMf n Date 2-8-20 <br /> O <br /> R ICC Installars Natter Dale Adams Exp Date 3-29-19 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 0.e.87 V ,n WO ,L=I&M) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions C Disapproved <br /> L 4Seai th Attachment V Conditions) <br /> A <br /> N Plan Reviewers Name DIRe r r f <br /> APPLICANT MUST PERFORM ALL WORK N ACCORDANCE WITH SAN JOAQUI+1 COUNTY OROINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CE RT WS THE FOLLOIINNG: h CERTIFY THAT IN <br /> THE PERFORMANCE OF THE W0W FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOW SUBJECT TO <br /> WORKERS COMPENSATION LAWS OF CALF A." CONTRACTOR'S HgRING OR SUBCONTRACTING TUBE THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE OF THE WOI�C F WHICH THIS PERMIT IS ISSUED,I SKOWL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> s �-" Tlla J < <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expanded beyond permit payment coverage per <br /> tank. If the party designated below Is dMerent than the permit applicant e.g. property owner, the party must <br /> acknowledges this responsibility for the billing by signature and date below. <br /> NAME Wilkey's Construction, Inc. TITLE Contractor PHONE* 530-741-2233 <br /> ADDRESS 4 Skyway Dr. Olive st, CA 95961 �y <br /> S1G UR r DATE '! G► <br /> RECEIVEE..'r <br /> MAR 9,9 2018 <br /> ENVIRONMENTAL <br />