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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 /> � Facility Name Gavinko Gas & Food Phone # 925 - 579 - 4865 <br /> I <br /> L Address7700 Moreland St , Stockton <br /> TCross Street E Hammer Lane <br /> Y Owner/Operator Harjinder Singh Phone <br /> # 925 - 579 -4865 <br /> C Contractor Name BZ Maintenance Phone # 916 - 371 - 2380 <br /> O <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 /> Q ICC Installer' s Name <br /> R See attached Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> ( i . e. 87 piping sump, 91 leak detector, UDC I etc. ) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> A � ( S Attachment With Conditions ) <br /> N I2� I2q <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK-IN-AC ORD fjE WIT�i SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY , ENVIRONMENTAL HEALTH DEPARTMENT . OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING : " I CERTIFY THAT IN <br /> THE PERFORMANCE OF THEK 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 TH ORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER ' S COMPENSATION LAWS <br /> F CALIFORNIA : ' <br /> Applicant's Signature TitleOxmner Date 8mi � 22 <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, nn n /'� <br /> NAME Gavinko Gas & Food TITLETW n e r PHONE # 925 - 579 -4865 <br /> ADDRESS 7700 Mu!TTM Stockton Q <br /> XNATURE DATE H ' 1 - 23 <br /> EH230038 (revised 12- 11 - 15) 2 <br />