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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 R ECENED <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> JUN 0 5 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT EWRONMENTAt- <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Ronnie Lewis 708-217-4181 <br /> y Chevron ( ) <br /> Facility Name Phone# 209 954-0945 <br /> 1 Address 1916 E March Ln, Stockton, CA 95210 <br /> L <br /> I Cross Street Bianchi Road <br /> T <br /> Y Owner/Operator Bhupinder Uppel Phone# (209)954-0945 <br /> C Contractor Name Nucleus Pump Services Phone# 916-382-4761 <br /> 0 <br /> N Contractor Address 601 1 st Ave, Suite B CA Lic# 949066 Class A-B- D40 <br /> T <br /> R <br /> A Insurer Wesco Insurance Company Work Comp# WWC3236024 <br /> T ICC Technician's Name Brian Roth Expiration Date 10/19/19 <br /> 0 <br /> R ICC Installer's Name Brian Roth Expiration Date 10/21/19 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name -Q" man an� 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 /> Applicant's Signature � � � '� Title Contractor Date 6/4/18 <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 Contractor PHONE# 916-382-4761 <br /> ADDRESS 601 1st Ave., Suite B, Sacramento, CA 95818 <br /> SIGNATURE DATE 6/4/18 <br /> EH230038(revised 08/1/11) <br /> 2 <br />