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i <br /> F <br /> RV : <br /> y 1 <br /> S <br /> MAR 13 2019 <br /> i <br /> Si A� " ���t" Environmental Health CepartmentAN ,. J dAQU INNv , RON � �N <br /> { <br /> ---- C0U1\ITY F7 l R) t I <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 /> O TANK RETROFIT d PIPING REPAiRIRETROFIT G UDC REPAIR/RETROFIT Q COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone X <br /> Facility Name Escalon Mini MadPhone # <br /> Address ' <br /> L 1097 F . Yosemite Ave , Ese1 <br /> Cross Street i <br /> Y Owner/OperatorBalwy Phone # 209 838-1546 <br /> c Contractor Name Phone # 2 1 <br /> O nonlee <br /> N Contractor Address 25 ro d Ave. Ceres CA . 5307 CA Llc # Class <br /> i <br /> R Insurer CW Work Comp # WPI 509-47,3201 . <br /> T ICC Technician's Name Miguel Zaragoza 8216444 Expiration Date 8/4/19 <br /> R ` ICC installer's Ndme Expiration Dale <br /> Mig Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> Q.e. 67 Dong sump, 01 look deledor, U0C 1124 elo.) Installed <br /> i <br /> N ' <br /> K i <br /> f <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> LS e ttachment With Conditions) <br /> A 711 G c; <br /> N Plan Reviewers Name Data <br /> APPLICANT MUST PERFORM ALL WORK IN ACC D WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEP MENT, 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: '1 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 /> ApplicanCeSignalure Tule Dale 1 /30/19 [ <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 Donlee Pump Company TITLE Amin PHONE # <br /> ADDRESS 2825 Rai { roaliA�/Q /er?S, GA 95307 <br /> SIGNATURE DATE 1130119 <br /> 2of6 <br />