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C <br />ENVIRONMENTAL EALHEAR11 �p � <br />SAN JOAQUIN COUNTY t$ <br />fr <br />1868 E. Hazelton Ave., Stockton, California 95205 8 2 0l <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 g <br />Vr IT.k I '%4 S <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 STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Bonnie Garber 209-537-9396 <br />Facility Name H & M Market J.Phone # 209-838-3971 <br />I <br />� <br />Address 2509 Jackson Ave. Escalon, CA. 95320 <br />I <br />T <br />Gross Street <br />Y <br />Owner/Operator Bo ett Petroleum <br />Phone # <br />C <br />o <br />Contractor Name Donlee Pum Company <br />Phone # - <br />N <br />T <br />Contractor Address 2828 Railroad Ave. Ceres CA Lic # 4320gg Class C61/D40 HA <br />R <br />A <br />Insurer <br />Work Comp # <br />cICC <br />TAnthnnyl <br />Technician's Name <br />Expiration Date 8/17/2017 <br />o <br />R <br />ICC Installers Name Anthony I.eislas <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 p(ptng sump, 91 leak detector. UDC 112, etc.) <br />T <br />A <br />N <br />K <br />€� <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <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 />Applicants Signature `%�ill'� Title Admin Date 4/28/2017 <br />T_ <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 />SIGNATU <br />EH230038 (revised 12-11-15) v 2 <br />TE 4128/2017 <br />