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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY a=- <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 APR 19 2016 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK !'+n �l�I��aa��, <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT 0 PIPING REPAIR/RETROFIT C UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Terry Masters 209461-6337 <br /> C Facility Name Vanco Truck and Auto Plaza Phone# 209-466-0833 <br /> I <br /> L Address 1003 West Charter Way Stockton <br /> TCross Street <br /> Y Owner/Operator Mike Phone# 209-466-0833 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Or Stockton Ca CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> C ICC Technician's Name Expiration Date <br /> T <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (IA.87 PIPWQ wrap,In max d r,uoc in.ox) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved .. Approved with conditions '._! Disapproved <br /> L ( ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 41-zz//4lp <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 AGENT'S 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 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 NARK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OFCAUFORNIA.' � <br /> Applimnrs Signature `//�^4"4"'�� <br /> 7 Tide Office Manager Date 4/19/16 <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 parry must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Carrie Miller/ Elite IV Contractors TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 25355 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE WL&4A, DATE 4/19/16 <br /> EH23003B(revised 07-17-2014) <br /> 2 <br />