Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY LL--,4LWVb_ - <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 14 201b <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact a Telephone# Megan Mitchell 209-461-6337 <br /> A Facility Name Arco AMpM Phone# 209-599-7600 <br /> Address 1340 Colony Rd Ripon Ca <br /> I <br /> T Cross Street <br /> Y Owner/Operator Ranjeet Singh Phone# 209-579-4014 <br /> C contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> T Contractor Address 253 Wi Wigwam Dr Stockt n a 95205 CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casualty Company work comp If MBUWC0133392 <br /> TICC Technician's Name Expiration Dale <br /> RICC Installers Name Expiration Date <br /> Tank system Work area Tank Size Chemicals Stored Currently Date UST <br /> (I.e.mnki. ,a1 Iw Be.aer.UCC W.MC) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S&A achment With Conditions) <br /> A &/Act <br /> N Plan Reviewers Name I Y )Alo Date <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: '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.' <br /> APPllcarx's Signature Tine Office Assistant Date 9/14/2016 <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# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Sto—c�k�ttonn Cal 95205 <br /> SIGNATURE DATE 9I14/2O16 <br /> EH230038(reVsed 12-11-15) 2 <br />