Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPART �LEIVEa <br /> SAN JOAQUIN COUNTY G <br /> 1868 E. Hazelton Ave., Stockton, California 95205 DEC 0 9 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br /> H Ir\CDA DTkd <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 ❑UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact 6 Telephone# Terry 209-461{337 <br /> C Facility Name Kludt Petroleum Phone# 209-368-0634 <br /> I <br /> L Address 1126 E. Pine St. Lodi CA 95240 <br /> 1 Cross Street <br /> T <br /> v Owner/Operator Steve Kludt Phone# 368-0634 <br /> G Contractor Name Elite IV Contractors Phone# <br /> O <br /> IN T Contractor Address 2535 Wigwam Dr. CA Lic# 1001331 Class A-Haz <br /> R Insurer Berkleynet Work Comp# NBUWC0133392 <br /> A <br /> D ICC Technician's Name Expiration Date <br /> T <br /> 0 ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 aphg Gump.91 leek ci.t. W,UDC In.W.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions Disapproved <br /> L S tta hmenl With Conditions) <br /> A n _i <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: N 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: 1 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 /> OFCALIFORNIA' /1��� � .�'A / <br /> Applicants SigmtUre C444"` rr�� Tale Office Manager Date 11/12/15 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. 0 <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 I Elite IV Contractors TITLE Office Manager PHONE# 209.461-6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton <br /> SIGNATURE <br /> e n DATE 11112/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />