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ENVIRONMENTAL LT E � T z„ <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 FaL,(209) 468-3433 az <br /> E VYV.k <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 REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name Tiwana Gas&Food Phone# 209477-3111 <br /> 1 Address 1210 E. Hammer Ln Stockton,CA 95210 <br /> L <br /> TCross Street <br /> Y Owner/Operator Dednder Tiwana Phone# 209-7150124 <br /> C Contractor Name Nucleus Pump Services Phone# 916-382-4671 <br /> 0 <br /> T Contractor Address 601 1 st Ave Suite B Sacramento,CA 95818 CA Lic# 949066 Class A-&D40 <br /> AInsurer Work Comp# <br /> C ICC Technician's Name Expiration Date <br /> T Todd Inderbitzen P 6/16/16 <br /> R ICC Installer's Name Todd Inderbitzen Expiration Date 7/6/19 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 0.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See ttachment With Conditions) <br /> A r <br /> N Plan Reviewers Name KI'Vel Date- I� l <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 IL/Z 41 Z41119� Title Date <br /> BILLING INFORMATION: <br /> Indicate the responsible parry to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the parry 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 Ronnie Lewis TITLE Service Manager(Contractor) PHONE# 916-3824761 <br /> ADDRESS 601 1st Ave Suite B Sacramento, CA 91818 <br /> SIGNATUREiE-�gis%e e!�uA DATE 8/30/17 <br /> EH230038(revised 08/1/11) <br /> 2 <br />