Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTIIQL �T- tl � <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 MAY 2 3 2016 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 R t^ <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 188 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie 209-461-6337 <br /> A <br /> C Facility Name Emil's Liquor Phone# 209-838-7674 <br /> L Address 1405 California St. Eacalon CA 95320 <br /> I Cross Street i <br /> T <br /> Y Owner/Operator Chacko Thomas Phone# 209-838-7674 <br /> Q Contractor Name Phone# <br /> o Elite IV Contractors 209 461-8337 <br /> N Contractor Address 2535 Wigwam Dr. Stockton 95205 CA Lic# <br /> T 9 1001331 Class A-HAZ ' <br /> A I Insurer Midwest Employers Casualty Work Comp# BNUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> RI ICC Installer's Name Expiration Dale <br /> Tank system work area Date UST <br /> (i.e.87 piping same,91 leak detector,UDC In.ac.) Tank Size Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K i <br /> i <br /> i <br /> i <br /> i <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �r 1'`l+Cl(A/(A� Date I—YCJ <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 AGENTS 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: '1 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" n " <br /> Applimnrs slgnstu (. Tine Office Manager Date 5/20/16 <br /> I <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If I <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this I <br /> responsibility for the billing by signature and date below. <br /> NAME Elite IV COntraCtOfS/Carrie Miller TITLE Office Manager PHONE# 209-461-6337 j <br /> 1 <br /> ADDRESS 2535 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE DATE 5/23/16 <br /> I <br /> EH230038(revised 07-17-2014) <br /> 2 j <br /> 1 <br />