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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 Igo DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW; <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT IXUDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Protect Contact & Telephone # Bonnie Garber 209-537-9396 <br /> AFacilit Name <br /> C y Tiger Express Phone # 209-623-3460 <br /> I Address <br /> L 1399 Yosemite Ave. Manteca, CA , 95336 <br /> TCross Street <br /> Y Owner/Operator Ruchi Vohra Phone # 559-905-9222 <br /> o Contractor Name Donlee Pump Company Phone It <br /> N Contractor Address 2825 Railroad Ave. Ceres CA Llc # 432089 Class <br /> A Insurer Work Comp # <br /> T ICC Technician's Name Alex Bramblla Expiration Date 3/10/2023 <br /> R ICC Installer's Name Alex Bramblla Expiration Date 3/10/2023 <br /> Tank system work area Tank Size Chemicals Stored Currently DateUedT <br /> (t,o, a7 piping sump, 91 look detector, UDC 12nsta <br /> , atom) i <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A qg j <br /> N Plan Reviewers Name N S 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, 1 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 Slgnatur Tlge Admin Date 6/28/2022 <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 bitting by signature and date below. <br /> NAME Bonnie Garber TITLE Admin PHONE # 209-637-9396 <br /> ADDRESS 2825 Railroad Ave. Ceres CA, 95307 <br /> SIGNATURE DATE 6/28/2022 <br /> EH230038 (revised 12-11 -16) 2 <br />