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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 0 C T 0 4 2016 <br /> APPLICATION FOR UNDERGROUND STORAGE TAN&VIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW. <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 209-461-6337 <br /> A <br /> C Facility Name West Lane Chevron Phone# 209-472-1639 <br /> 1 Address 4747 N. West Lane Stockton CA 95205 <br /> L <br /> TCross Street <br /> Y Owner/Operator Rinku Phone# 209-992-1735 <br /> C Contractor Name Elite IV Contractors Phone# <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr Stockton CA Lic# 1001331 Class A-Haz <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> TICC Technician's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i a 87 piping sump.91 leak detector,UDC ill.etc) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved X Approved with conditions F] Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name A <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY DINANCES,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 1,§i ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMP ON LAWS OF CALIFORNIA." CONT CTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PE ORMA CE OF THE WORK F I H THI P BRIT IS ISSUED, SHALL EMPLO PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signat <br /> BILLING INFRMATION: <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 Carrie Mi r' Elite IV Contractors TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2`35 W gwam Dr Stac 205 <br /> SIGNATURE /30/16 <br /> 0 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />