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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY L�NjLr b <br /> 1868 E. Hazelton Ave., Stockton, California 95205 AUG 2 q 21016 <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 D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan Mitchell <br /> C Facility Name Kludt T--kinq Phone# 209-461-6337 <br /> � Address 1126 E Pine St Lodi Ca 95240 <br /> 1 Cross Street <br /> T <br /> v Owner/Operator Steve Phone# 209-466-8969 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> RContractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> TICC Technician's Name <br /> Expiration Date <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Date UST <br /> (16 87 PION surra,9f leak detector.UDC fit,etc.) Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved With conditions ❑ Disapproved <br /> A (See <br /> Attachment With Conditions) <br /> N Plan Reviewers Name_` CW 1"�?N ) /-ij A" - ? <br /> 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: '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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' �7,r <br /> PPliCanes signature /✓�� TitleDate 8/24/2016 <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 Off G2 A aL9tant PHONE# 209-461-6337 <br /> ADDRESS 2535 Wiawam Dr Stockton C/a n5 <br /> SIGNATURE DATE 824/2016 <br /> EH230038(revised 12.11-15) 2 <br />