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v <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> FILE 1868 E. Hazelton Ave., Stockton, Calffomia 95205 RECEIVED <br /> OPV Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEC 16 2015 <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: HEALTH DEPARTMENT <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> A EPA Site# Project Contact&Telephone# Carrie 209-461.6337 <br /> C Facility Name Costco#658 phone# <br /> 1 Address 3250 W. Grantline Rd Tracy CA -834-1247- <br /> I <br /> T Cross Street <br /> y Owner/Operator Costco_Ton Ha ab phone# <br /> NContractor Name Elite IV Contractors Phone# 209-461-6342 <br /> rs Contractor Address 2535 Wigwam Dr Stockton CA Lie# 1001331 Class A-HAZ <br /> A <br /> Insurer Work Com #Barkley net P NBUWC0133392 <br /> TICC Technician's Name <br /> O Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system Work area <br /> 06 Vpipkp sumo.91 leak aeal:ta.UDC In,W,) Tank Size Chemicals Stored Currently Date <br /> LISTInstalled <br /> T <br /> A <br /> N <br /> K <br /> P E Approved X Approved with conditions E Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> Date /a -.2 3/S <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNT ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAGUIN 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 W SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKERS 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 /> OF CALIFORNIA.' n <br /> Applicanra Signewre Tile Office Manager Dale 12/16/15 <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 Contrcators -Carrie Miller TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Or-7Stockton CA 95205 <br /> C.� <br /> SIGNATURE DATE 12/16/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />