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Vb <br /> SAN J O A Q U I N Environnnen �� LVL 1 Pa �rtt�'"nt <br /> - COUNTY <br /> AUG 2 1 2023 <br /> APPLICATION FOR UNDERGROUND STORAGF�T`/� W6NNIENTAL 1-IEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT I) 14ytI1 riNIENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT Z PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CAD983600594 Project Contact & Telephone # Greg Slunaker 951 -538- 1941 <br /> y Kaiser Stockton Medical Offices <br /> Facility Name Phone # 209 456 2031 <br /> I Address 7373 West Lane , Stockton CA 95210 <br /> L <br /> I Cross Street Hammertown Drive <br /> T <br /> Y Owner/Operator William Haena Phone # 209 456-2031 <br /> c Contractor Name Tank-Tek Environmental Corp Phone # 951 779 4999 <br /> 0 <br /> N Contractor Address PO Box 5850 CA Lic # 803705 Class A <br /> T <br /> R <br /> A Insurer State Fund Work Comp # <br /> C <br /> T ICC Technician ' s Name Greg Slunaker Expiration Date 11/10/2024 <br /> R ICC Installer's Name Greg Slunaker <br /> Expiration Date 11/10/2024 <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 above ground piping modification 12000 diesel <br /> A new trans sump with VR 420 sensor <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ,.(Se achment With Conditions) <br /> N Plan Reviewers Name I \ 1 Date 11 I I2V <br /> APPLICANT MUST PERFORM ALL WORK IN ACO DAN WI AN UIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> APPLICANT MUST PERFORM ALL WORK IN AGUO DA <br /> COUNTY, ENVIRONMENTAL HEALTH D PARTM 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 WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature rireg�,S&Waker Title Contractor Date 8/18/2023 <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 Greg Slunaker TITLE Contractor / President PHONE # 951 538 1941 <br /> ADDRESS PO Box 5850, Riverside CA 92517 <br /> SIGNATUREDATE <br /> 8/18/2023 <br /> 2 of 6 <br />