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• 0 <br />ENVIRONMENTAL HEALTH DEPA VENED <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave.. Stockton, California 95205 JAN 0 5 2018 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TAVRONMENTAL HEALTH <br />RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL CATE INOICATE PERMIT TYPE BELO'v., <br />D TANK RETROFIT C PIPING REPAIRIRETROFIT '' UDC REPAIR/RETROFIT a COLD STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact $ Telephone # <br />- <br />A <br />C <br />Facility Name George Kishida Inc. <br />Phone # 209-368-0603 <br />Address 1725 Ackerman Drive Lodi, Ca 95240 <br />TCross <br />Street Maxwell street i <br />Y <br />Owner/Operator Kelli Kishida Phone # same as above <br />p <br />Contractor Name MVP Petroleum Engineering Inc. Phone # 916-984-1537 <br />N <br />T <br />_ <br />Contractor Address PO Box 281 Folsom, Ca 95763 -- i CA LIC # 768938 Class A B Haz <br />A <br />Insurer see attached <br />Work Comp # see attached <br />T <br />ICC Technician's Name see attached <br />Expiration Date see attached <br />R <br />ICC Installer's Name see attached <br />Expiration Date see attached <br />Tank system work area <br />Tank Size Chemicals Stored Current) y <br />Date UST <br />I e. 87 pprq surra 91 leak setWnr UDC e4 etc <br />Installed <br />J5..__�..v.-... <br />N <br />K <br />_- <br />I <br />I <br />P <br />_ Approved Approved with conditions _. Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />/�� <br />Plan Reviewers Name &�S r ;FaVW cCA 1 �O S-1/�' <br />Date <br />APPLICANT 61UST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS. AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COLINTY. ENVIRONMENTAL HEALTH DEPARTMENT OWNER OR L'CENSED AGENT'S SIGNATURE CERTIF'ES THE FOLLOWING `I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED � SHAL.L NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S MIR+NG OR SUBCONTRACTING SIGNAT„-RE CERTIFICS THE FOLLOWING "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR -L kJa TH S PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" <br />v <br />AppltcentsSignature �� TNe ''"� "^'Dare 12/15/2017 <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. 9 9 property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME BZ Service Station Maintenance TITLE Project Manager PHONE # 916-371-2380 <br />Imll <br />PO Box 933, West a ram nto, Ca 95691 <br />Emilv Crain, <br />EH230038 (revised 12-11-15) <br />12/15/17 <br />