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i <br /> ENVIRONMENTAL HEALTH DEPARTMENt-lii.;Ll,,4 ►_:. <br /> SAN JOAQUIN COUNTY JUL 11 2016 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 'ti i � ftM <br /> i <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 /> O TANK RETROFIT n PIPING REPAIRIRETROFIT O UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact x Telephone# Terry Masters 461-6337 <br /> A Facility Name Phone# <br /> c tY Vano Truck&Auto Plaza 209-466-0833 , <br /> I <br /> L Address 1033 W. Charter Way Stockton CA 95205 <br /> TCross Street <br /> Y OwnedOperator Mike Phone# (916) 396-1665 <br /> o Contractor Name Elite IV Contractors Phone# <br /> N Contractor Address 2535 Wigwam Dr Stockton CA 95205 CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casualty Work Comp# BNUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name I Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping gang.91 leak tlelecloa UDC 1Q,etc l Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved V37 Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A ''7 Q <br /> N Plan Reviewers Name Data <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: "I 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" �j������ �iwn,�� <br /> Applicant's Signature `a'---- w" '_""'"_ Title Office Manager Dale 7/11/16 <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 party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Elite IV Contractors/Carrie Miller TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE K_Ia_4 � i'/CLY.Y.PIL, DATE 7/11/16 <br /> EH230038(revised 07-17-2DI4) <br /> 2 <br />