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ENVIRONMENTAL HEALTH DEPAR ..MENT.. <br /> SAN JOAQUIN COUNTY LZ �a [ 1. In D <br /> 1868 E. Hazelton Ave., Stockton, California 95205 MAR ` 8 2017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANKIWIRONMENTA! HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DFPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan 209-461-6337 <br /> A <br /> C Facility Name Georges Mini Mart Phone# 209-814-3581 <br /> I Address 18662 Highway 88 Lockeford Ca 95237 <br /> L <br /> TCross Street <br /> Y Owner/Operator Bill Phone# 209-814-3581 <br /> c Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> 0 <br /> NCA Address 2535 Wigwam or Stockton Ca 95205 CA Lic# 1001331 Class A-Haz <br /> T <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> T ICC Technician's Name Expiration Dale <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 1i.e.87 piping wrnp.91 leek deWcWr,UDC 12,eW.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> ISIN 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 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: '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.' -7,,1 <br /> Applicant's Signature /�li%C1 <br /> " Tlge Office Assistant Date 4/27/2017 <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 Office Assistant PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam or Stockton Ca 95205 <br /> SIGNATURE I% L lZt"LGGCIl DATE 4/27/2017 <br /> EH230038(revised 12-11-15) 2 <br />