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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 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 # Margaret Smith 9163- 71 -2380 <br /> A <br /> c Facility Name Gavinko Gas & Food Phone # 925-579-4865 <br /> I <br /> L Address 7700 Moreland St , Stockton <br /> TCross Street E Hammer Lane <br /> Y Owner/Operator Harjinder Singh Phone # 925 -5794865 <br /> C <br /> 0 Contractor Name BZ Maintenance Phone # 916- 371 -2380 <br /> T Contractor Address PO Box 933 , W Sac 95691 CA Lic # 433159 Class A B C-61 D40 <br /> A Insurer See attached Work Comp # See attached <br /> T ICC Technician 's Name See attached Expiration Date <br /> o ICC Installer' s Name Expiration Date <br /> R See attached p � <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( S Attachment With Conditions) <br /> A o l >, <br /> N Plan Reviewers Name Date J <br /> t <br /> APPLICANT MUST PERFORM ALL WORK--W-ACItORDANIC,E 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 K FOR WHICH THIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER 'S COMPENSATIO LAW F CALIFORNIA." CONTRACTOR 'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN E OF THNNORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> F CALIFORNIA ." <br /> >< Applicant's Signature Title OlAine. r Date 8ml � 23 <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 billing by signature and date below. <br /> NAME Gavinko Gas & Food TITLEW n e 1r <br /> PHONE # 925 -5794865 <br /> ADDRESS 7700 Mor Stockton Q ♦ n <br /> XIGNATURE DATE & I - 3 <br /> EH230038 (revised 12- 11 - 15) 2 <br />