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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 AUG I 12017 <br /> Telephone: (209) 468-3420 Fax: (209) 4683433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANR%'V1R0NWJ-­T,,' h d H <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT Ei COLD STARTIEVIR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan 209-461-6337 <br /> A <br /> C Facility Name Vanco Phone# 916-396-1665 <br /> I Address 1033 W Charter Way Stockton Ca 95206 <br /> L <br /> T I Cross Street <br /> Y OwnerlOperator Mike Popari Phone# 916-396-1665 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> 0 <br /> N Contractor Address 2535 VVogwam Dr StocktQn C-a-9-9205 CA Lie# 1001331 Class A-HAZ <br /> T <br /> R Workcomp# BNUWC0133392 <br /> A insurer Midwest Employers Casualty Company <br /> C <br /> T ICC Technician's Name Expiration Date <br /> 0 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date LIST <br /> (Le.87 Piping sum 91 leak detector.UDC 112.etc.} Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name e�le ' r- Date_oc�' Z�*- // <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: 1 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 ASTO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNTA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> lAppllraffs Signature p0q), Wcheu Title I A Date $111/2017 <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 Megan Mitchell TITLE Office Assistant ..PHONE# 2QR-Afij-63 <br /> 37 <br /> ADDREss 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE Meam Wchea DATE 8/11/2017 <br /> EH230038(revisad 12-11-15) 2 <br />