Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. HazeIton Ave., Stockton, California 95205 JUN 0 2 2017 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANORONMENTAL HEAL-H-1 <br />RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />13 TANK RETROFIT 0 PIPING REPA1R/RETROFIT 0 UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br />F <br />A c <br />I L <br />I <br />T <br />Y <br />EPA Site # Project Contact & Telephone # Megan Mitchell 209-461-6337 <br />Facility Name Short Stop Phone # 559-366-0699 <br />Address 20 W Turner Rd Lodi Ca 95260 <br />Cross Street <br />Owner/Operator Sam Hirsch Phone # 559-366-0699 <br />0 C <br />1,4 <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />Contractor Name Elite IV Contractors Phone # 209-461-6337 <br />Contractor Address CA Lic # 1001331 Class 2535 Wigwam Dr Stockton Ca 95205 A-HAZ <br />Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br />ICC Technician's Name Expiration Date <br />ICC Installer's Name Expiration Date <br />T <br />A <br />N <br />K <br />Tank <br />(i.e. 87 piping sump, <br />system <br />eak tleleclor, UDC 1/2, etc.) <br />work area <br />91 l Tank Size Chemicals Stored Currently Date UST <br />Installed <br />P <br />L <br />A <br />N <br />Ell Approved -pp roved with conditions D Disapproved <br />(See T1achment With Conditions) <br />„.-------72---- _____..--,---- c <br />Plan Reviewers Name/- .- Date ....k <br />C._. _- <br />APPLICANT MUST PERFORM ALL WpRK 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 />Applicants Signature . il/legan MI tha -rft Office Assistant (Date 6/2/2017 <br />BILLING INFORMATION: <br />Indicate the responsible party to he 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 /> <br />ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br />SIGNATURE <br /> <br />Megan Mitcha <br /> <br />DATE 6/2/2017 <br /> <br />EH230038 (revised 12-11-15) 2