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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <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 ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Terry Masters <br /> A <br /> C Facility Name West Lane Fuels Phone# 209-466-1682 <br /> I Address 3300 N. West Lane Stockton CA <br /> L <br /> TCross Street <br /> Y Owner/Operator Stockton Petroleum Phone# 209-462-8707 <br /> o Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> T Contractor Address 2535 Wigwam Dr. CA Lic# 1001331- Class A-HAZ <br /> A Insurer Midwest Employers Casualty Work Comp# BNUWC0133392 <br /> C ICC Technician's Name <br /> T Expiration Date <br /> oIGC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) y <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> r_I <br /> P Approved rX Approved with conditions J Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date ® 1 <br /> s <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 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 /> Applicant's Signaturerifle Office Manager Date 8/3116 <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 Contractors-Carrie Miller TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam <br /> 7D,,r/Stockton CA <br /> SIGNATURE (�- i WKI& DATE 8/3/16 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />