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RECEIVEL <br /> ENVIRONMENTAL HEALTH DEPARTMEWB o4 2016 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> 1868 E. Hazelton Ave., Stockton, California 95205 HEAITN r1ca.,trrry pNT <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 209-461-6337 <br /> A <br /> C Facility Name Woodbrige Arco Phone# 209-339-8238 <br /> � Address 18970 Lower Sacramento Woodbrige CA <br /> I Cross Street <br /> T <br /> Y Owner/Operator Jazz Enterprises Phone# 209-339-8238 <br /> o Contractor Name Elite IV Contractors Phone# 209461-6337 <br /> E <br /> T Contractor Address 2535 Wigwam Dr. Stockton CA CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casuality Company Work Comp# BNUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i e.87 piping sump,91 leak 4electa,UDC Ia.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved / pproved with conditions ElDisapproved <br /> L I (I AHachment With Conditions) <br /> A �-� <br /> N Plan Reviewers Name � � 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: "t 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" �'A .�A <br /> Appllrnrs Signalure //Le'.&6' Tine Office Manager Date 2/4/16 <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 Carrie Miller /Elite IV Contractors TITLE Office Manager PHONE# 209-461-6337 <br /> ADOREss 2535 WigwamnDr <br /> SIGNATURE ! 2L2L2 DATE 2/4/16 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />