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I <br /> SAN IOAQUIN <br /> Environmental Health Department <br /> APPUCATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES iso DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE MOW <br /> 0 TANK RETROFIT O PIPING REPAWASTROFIT 0 UDC REPAMItCMOFIT 0 COLD START(EM UPGRADE <br /> F EPA Site# Project Contact a Telephone# <br /> � Facility Name Kaiser Permanente North Phone# <br /> I Address 7373 West Lane, Stockton, CA <br /> L <br /> T Cross Street <br /> Y OwnerADperator Phone# <br /> o Contractor Name Wilkey's Construction, Inc, Phone# 530-741-2233 <br /> T ContraCWAddness 4557 Skyway Dr. Olivehurst, CA CALX# 722945 CM A HAZ 8 <br /> Insurer Dick Harris Insurance Agency Work Comp# 3995665472013 <br /> T ICC Technician's Name Jesse Nelson Expiration DSte <br /> z-a-26 <br /> R ICC instane Name Dale Adams Expiration Date 3-29-19 <br /> Tar*sydem work areaDeftUST <br /> 0.e.07OW4%M,St"NOW UDC 1R.MCI Tank Size CllerrllCS1=Stored CUrrendy installed <br /> T <br /> A <br /> N <br /> K <br /> p C Approved Approved with conditions E Disapproved <br /> L -(See!lttacixnent ,With Conditions) <br /> A <br /> N Plan Reviewers Name Dale _ � ��� <br /> APPLICANT MUST PERFORM ALL WORK WNCE AW WITH SJOAOUIft COMITY ORDI N►MMS.STATE LAWS,AND RULES AND REGULATIONS OF SMI <br /> JOAQUIN COUNTY,ENNROMAENTAL IIE/ILTIi I1RT1tfT.OWNER OR LICENSED AGENTS SIGNATURE CEFtT>flE8 THE FOLLOWING: 7 CERTIFY THAT W <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERWT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A$TO W40ME SUBJECT TO <br /> WORKERS COMPENSATION LAWS OF CAllf CONTRACTOR'S MOW OR SUBCONTRACTING SIGNATURE CERTrIES THE FOLLOWING. I CERTIFY <br /> THAT MI THE PERFORMAWCE OF THE WORK f WHICH THS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SU9,ECT TO WORKER'S COMPENSATION LAWS <br /> OF CALYORNUI <br /> • Ta ✓ 00, <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 On responsibility for the billing by signature and date below. <br /> NAME Wilkey's Construction, Inc. TITLE Contractor P80NES 530-741-2233 <br /> ADDRESS 4 Skyway Dr. Olive rst, CA 95961 <br /> SIG UR DATE 3 -Z6 / Sr <br /> 2oT8 RECEIVED <br /> MAR 9-9 18 <br /> ENVIRONMENTAL <br /> E <br />