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To: Elena Manzo Page 8 of 13 2018-09-05 16:47:04(GMT) 17076380484 From: Nucleus Pump Services <br /> JOAQUIN I V`E D <br /> Environmental HealaQ amt <br /> f. c7]J1 ; N-r'Y-,...._. SEP 05 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK EN\PRONMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT HEALTH DEPAQTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Ronnie Lewis 916-382-4761 <br /> A <br /> C Facility Name Power Mart Phone# (209)239-1792 <br /> I <br /> L Address 1434 W Yosemite Ave,Manteca,CA 95337 <br /> 1 Cross Street Watson Ave <br /> Y Owner/Operator Colonial L'nergy,LLC. Phone# (714) 761-5426 x295 <br /> C Contractor Name Nucleus Pump Services Phone# 916-382-4761 <br /> N <br /> T Contractor Address 601 1st Ave.,Suite B, Sacramento,CA 958181 CA Lic# 949066 Class A-B-D40 <br /> A Insurer Wesco Insurance Company Work Comp# WW(3236024 <br /> T ICC Technician's Name Brian Roth <br /> T Expiration Date 1.0/71/19 <br /> R ICC Installer's Name Brian RoLh Expiration Date 10/21/19 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (ho.87 piping cutup.91 leak detector,UDC 112,etc.) Installed <br /> T 89 UST 89 Lo be converted Lo Diesel <br /> A <br /> N <br /> K <br /> P C Approved Approved with conditions ❑ Disapproved <br /> L S Attachment With Conditions) <br /> A (�, 2 <br /> N Plan Reviewers Name OAA Date w�')"�0 1Q, " <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' "1 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 '"" � ^" � Title Contractor Date 8/16/18 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME <br /> Ronnie Lewis 11TLE Contractor PHaNE# 916-382-4761 <br /> ADDRESS 601 1st Ave.,Suite B,Sacramento,CA 95818 <br /> SIGNATURE ' e"1" """ � DATE 8/16/18 <br /> 2 ot6 <br />