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i <br /> I <br /> I <br /> . I <br /> ENV � I-Fnf� �VfL �l �f� L HEAL. ri i DEPARTMENT <br /> SAN JOAQUIN COUNTY RII10EI \% L� �+J) <br /> 1868 E . I•tcrizelton Ave . , Stool ( tori , Ctalifot'nla 96205 <br /> Telephone; (200) 466 - 3420 Fax: (209) 468> 3433 �� ,� �� 1 i{ )()?.'1. <br /> APPLICATION I4OR UNDERGROUND STORAGE 1'; 010NIVIENTAI _ I li'_ A1 111 <br /> RETRorIT OR PIPING REPAIR PERMIT Pl -: RMIT/ %k1I RVIGF- -; <br /> THIS PERMIT EXPIRES fe0 DAYS FROM THE APPROVAL DATE, INDICATE. PPRIMT TYPE BELOW: <br /> O 'I'ANI( RETI1OrIT O PIPING REPAIRIRETROFIT MUDC REPAIRINETROFIT 000I.D S1'ARTIEVR UPGRADR <br /> r EPA Site 11 Project Contact & Telephone it Bonnie Garber 200-0M390 <br /> C f=acility Name Escalon MIn1 Mart Phone ,I 200.0311-ib4f3 <br /> I. <br /> Address 1007 E , Yosemite Ave. Escalon, CA , <br /> I Cross Street <br /> T Phonoll 20fl-637 03flR <br /> Y Owner/Operator galw nc or sinnh <br /> o Contractor Name Doniee Pump Company Phone 11 OQ. n t7 _n34(� <br /> N Contractor Address 2828 Railroad Ave. Ceres CA Lie f1 432000 Class <br /> T Work Comp I'1 <br /> A Insurbr <br /> T ICC Technician's Name Gerardo Perez Explrallon Date 3194122 <br /> ° ICC Installers Name Expiration Dale <br /> R <br /> 1'ank system work area Date UST <br /> Y Tank Size Chemicals Stored Currently Installed <br /> Q.o. 0) ptpnp sump, D t leak del¢Ua. UAC fR, Olay <br /> T <br /> A <br /> N 4 <br /> t< j <br /> I <br /> P IJ Approved Approved vAlli conditions 0 Dlsepprovod <br /> L (Se Attachment With Conditions) I <br /> A <br /> N Plan Reviewers Nantee Q pate — <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RUOULATIONS OF SAu <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING: 01 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 SUBJIEOT TO <br /> ORKER'S COMPENSATION LAWS OF CALIFORNIA! CONTRACTOR'S HIRING Oil SURCONTRACTING SIGNATURE CERTIFIES THEIFOLLOWINo$ 'I CERTIFY <br /> THAT IN Tilt; PBRFORMANOE OF THE WO 'OR WHICf{ TtIIS PERIAIT IS ISSUED, I St{ALL EMPI.OY PERSONS SUBJFOT TO WORKER'S COMPIENSA11ON LAWS 1 <br /> OF CALIFORNIA" A - <br /> A Yconl'sSlOnaluro� t � 7N° Dato12$f <br /> BILLING INFORMArm . <br /> Indicate the responsible party to be billed for edd(tlonal E;HD staff time expended beyond perimll payment coverage per lank. If <br /> ilia party designated below is different than lila permit appileant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and dale below. <br /> NAME.0 jn e G rber .TITLE Admltl PHONE fI, 20()- 037-43213 <br /> ADDRESS 2025 Rallroad A a Ceres CA. 26307 + <br /> SIGNATURC -� <br /> DATE 120122 _ <br /> E11230030 (tovleod 12-11 18) 2 <br /> fJ <br /> I <br />