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10 <br /> ENVIRONINTAL HEALTH DEPARTMENT <br /> 17 <br /> SAN JOAQUIN COUNTY R V", D <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 FqJ209) 468-3433 SEP 0 6 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TAWIVRONMENTAL DEALT; <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT 0 COLD STARTIEVIR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Tiwana Gas&Food Phone# 209477-3111 <br /> 1 Address 1210 E.Hammer Ln Stockton,CA 95210 <br /> L <br /> T I Cross Street <br /> Y Owner/Operator Derinder TiWana Phone# 209-715-0124 <br /> c Contractor Name Nucleus Pump Services Phone# 916-3824671 <br /> 0 <br /> N <br /> T Contractor Address 601 1 st Ave Suite B Sacramento,CA 95818 TCA Lic# 949066 Class A-B.D40 <br /> R <br /> A Insurer Work Comp# <br /> C <br /> T ICC Technician's Name Todd Inderbitzen Expiration Date 6/16/16 <br /> 0 <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 /> (i.e.87 piping sump,91 leak detector,UDC 1/2,eto.) 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 Reviewers Name Date <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 /> jApplicent's Signature Ame," ZA4ve-, <br /> Title Sg[yige Mlinggr(QQnjMctor) Date 8130117 <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- Ronnie Lewis —TITLE Service Manager(Contractor) PHONE# 916-3824761 <br /> ADDRESS 601 1st Ave Suite B Sacramento,CA 91818 <br /> SIGNATURE iuu.2 Z_AzDATE 8/30/17 <br /> EH230038(revised 08/1/11) <br /> 2 <br />