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f <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209 ) 468 -3420 Fax : ( 209 ) 468 -3433 <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 IN PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Bonnie Garber 209- 537-9396 <br /> A <br /> C Facility Name ER Vine Stockton Phone # 209-537-0723 <br /> 1 Address <br /> L ER Vine 4733 S . Hwy 99 Frontage Rd , Stockton , CA, <br /> I Cross Street <br /> T <br /> Y Owner/Operator Richard Erickson Phone # 209-537-9396 <br /> c Contractor Name Donlee Pum Company Phone # <br /> o <br /> - - <br /> N Contractor Address 2825 Railroad Ave . Ceres CA Lic # 432089 Class C61 /D40 HA <br /> T <br /> R <br /> A Insurer Work Comp # <br /> C ICC Technician ' s Name Expiration Date <br /> T Miguel Zaragoza 8216444 p 8/9/2021 <br /> R ICC Installer's Name Miguel Zaragoza Expiration Date 8/9/2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved VApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A i <br /> N Plan Reviewers Name �'�^^ 1 Date.() Z 1 Z f.� <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. " <br /> Applicant's Signature Tide Admin Date 7/16/2020 <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 Bonnie Garber TITLE Admin PHONE # 209-537-9396 <br /> ADDRESS 2825 Railroad Ave . Ceres CA , 95307 <br /> SIGNATURE DATE' 7/16/2020 <br /> EH230038 (revised 12- 11 - 15) 2 <br />