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ENVIRONQENTAL HEALTH DOARTMENT <br /> SAN JOAQUIN COUNTY RECD JUL 27 2015 <br /> 1868 E. Hazelton Ave., Stockton, Califomia 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie <br /> A Facility Name Phone# <br /> C Charter Way Chevron 209-465-3440 <br /> Address <br /> L 508 W. Charter Way <br /> I Cross Street <br /> T <br /> Y Owner/Operator Rinku Singh Phone# 209-992-1735 <br /> CContractor Name Elite IV Contractors Phone# 209-461-6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr. CA Uc# 660076 Class ABC10 HAZ <br /> R Insurer MarkelWork Comp# MWC0070230 <br /> A <br /> C ICC Technician's Name <br /> 7 Expiration Date <br /> G <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> rya.97 pipiM epmp,91 mak detector,UDC 1a, .> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (SIA With Conditions) <br /> A 1 <br /> N Plan Reviewers Name 2 Q .nZ!� 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 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" CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM E OF THE WORK FOR WHICH IS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" r� yp <br /> Appliranl'a Signanae Ay�A.(.L � J / , u Title Office Manager Date 5/14/15 <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 TITLE Office Manger PHONE# 209-461-6337 <br /> ADDRESS 1�q Wigwam Dr. Stockton CA• <br /> SIGNATURE ` !ZAZDATE 7/24/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />