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Environmental Health � Dep? rtment <br /> SAN , JOAHIN <br /> C O U N `l- <br /> YY��. <br /> APPLICATION FOR UNDERGROUND STORAG 1�/ � E � i � <br /> RETROFIT OR PIPING REPAIR PERMIT ` , ` „ <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209.461 -6337 <br /> A <br /> C Facility Name Kludt Trucking Phone # 209A(36-8969 <br /> I <br /> L Address 1126E Pine St Lodi Ca 95241 <br /> TCross Street <br /> Y Owner/Operator Steve Kludt Phone # 209-466-2969 <br /> C Contractor Name Elite IV Contractors Phone # 209-461 -6337 <br /> O <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A.HAZ <br /> T <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> C <br /> T ICC Technician 's Name Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ ApprovedApproved with conditions El Disapproved <br /> L LAeAltachment With Conditions) <br /> A %Ft <br /> NFlo <br /> Plan Reviewers Name Date_ r lon <br /> APPLICANT MUST PERFORM ALL WORK 1 CORDANC -WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPART ENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS RMIT 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 PERFORMA CE OF THE WORK FOR ICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> pplicant's Signature Qe Office Assistant Date 6/25/2020 <br /> I LING INFORMATION : <br /> Indicate the responsible party to be billed fora Tonal EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Megan Mitchell TITLE Office Assistant PHONE # 209461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE " DATE 6/25/2020 <br /> ,i <br /> 2of6 <br />