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SANJOAQUIN Environmental Health Department <br /> -- COUNTY <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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Robert Marry / 800-511 -9300 <br /> Facility Name Express - Stockton <br /> Phone # 209-982- 1841 <br /> I <br /> L Address 7611 Airport Way, Stockton , CA 95206 <br /> TCross Street East Stimpson Road <br /> Y Owner/Operator GI Trucking dba Estes West (Terminal Manager - Bill Wardell) Phone # 209-982-1841 <br /> 0 Contractor Name Gettler Ryan Phone # <br /> O Y (916) 851 . 183C) <br /> N Contractor Address 1050 Riverside Pkwy Ste 115 , West Sacramento , CA 9560 CA Lic # 220793 Class <br /> T A-HAZ <br /> R <br /> A Insurer Work Comp # <br /> TICC Technician ' s Name Derreq Knaules Expiration Date 06/05/23 <br /> RICC Installer' s Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T Diesel Tank - Leak Detector Replacment Diesel <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL W RK IN ACCORDANC 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 WdICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title <br /> President/AdvancedGeo/Consultant Date 09- 19- 22 <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 parry must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME AdvancedGeo , Inc. TITLE Consultant PHONE # 800-511 -9300 <br /> ADDRESS 837 Shaw Road , Stockton , CA <br /> SIGNATURE DATE 09 19m22 <br /> 2of6 <br />