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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209) 468 - 3420 Fax : (209 ) 468 -3433 <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 /> 0 TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Bonnie Garber 209-537-9396 <br /> � <br /> Facility Name Van De Pol Phone # 209-242-5248 <br /> I Address 816 E . Frontage Rd . Ripon , CA. 95366 <br /> L <br /> I Cross Street <br /> T Phone # <br /> Y Owner/Operator Carlos Coria <br /> C Phone # <br /> " <br /> ° onracpump <br /> CA Lic # Class C61 /D40 HA <br /> N Contractor Address 2825 Railroad Ave . Ceres 432089 <br /> T Work Comp # <br /> R Insurer <br /> A Expiration Date <br /> Name Romero / Anthonyeivas <br /> T <br /> CC Technician ' s Nam Mario Rom Y <br /> to 20 <br /> Expiration Da 1 /12/20 <br /> R ICC Installer' s Name Miguel Zaragoza <br /> p <br /> R Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) <br /> T <br /> A . <br /> N <br /> K <br /> i..} • I i - <br /> =RevViiewers <br /> Approved with conditions Disapproved <br /> PL (See Attachment With Conditions) <br /> A NDate bGil.. <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 /> THATLLOWING : "I CERTIFY <br /> IN THE COMPENSATION LAWS <br /> OF THOF CALIFORNIA.E WORK FOR WHICH°T IS PETRMIT ISIISISUED ,NG RI SHALLOEMPLOYIPERSONS SUBNG S CT TO WORKER'CERTIFIES THE S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature <br /> Title Admin Date 3/12/2019 <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 /> ADDRESS 2825 Railroad Ave . Ceres CA . 95307 <br /> DATE 3/12/2019 <br /> SIGNATOR <br /> 2 <br /> EH230038 (revised 12- 11 - 15) <br />