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ENVIRONMENTAL HEALTH DEPAR <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 1°� 2 20l'i <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />i b . 0 f - <br />a 111 o AU 1:110 Le '11Z4=1 .41TI <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />U TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # Bonnie Garber 209-537-9396 <br />� <br />Facility Name H & M Market Phone # 209-838-3971 <br />I <br />L <br />Address 2501 Jackson Ave. Escalon, CA. 95320 <br />TCross <br />Street <br />Y <br />OwnerlOperator Bo ett Petroleum <br />Phone # <br />C <br />o <br />Contractor Name Pum Com an <br />Phone # <br />- - 9396 <br />NContractor <br />T <br />epontes <br />Address 2825 Railroad Ave. Ceres <br />CA Lic # 432089 Class C61 /D40 HA <br />R <br />Insurer <br />Work Comp # <br />A <br />ciCC <br />T <br />Technician's Name <br />Expiration Date 8/17/2017 <br />OICC <br />R <br />Installer's Name <br />Anthony Lei�vaq <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />p.e. 87pi tg sung, 91 Ieekdetwor, Luc tl2, etc.) <br />T <br />A <br />N <br />K <br />❑ ❑ Approved ❑ Disapproved <br />P <br />Approved with conditions <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />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 AGENTS 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 />ApFIicani'sSignature Title Admin -Pate--4/2&2D-1 7 <br />0 ) 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 />SIGNA <br />EH230038 (revised 12-11-15) v 2 <br />TE 4/28/2017 <br />