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RECEIVED <br /> DEC 15 2015 <br /> ENVIRONMENTAL HEALTH DEPARTM ,` H DEPARTMENT <br /> NT <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 0 PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# <br /> A Project Contact&Telephone# Carrie Miller 209-461.6342 <br /> C Facility Name Flame Liquors Phone# <br /> Address 209-334-3233 <br /> 1 <br /> L 1301 Kettlmen Lane Lodi CA <br /> TCross Street <br /> v Owner/Operator Rupi or Bili <br /> Phone# 209-914-8735 <br /> C <br /> Contractor Name Elite IV Contractors Phone# <br /> RContractor Address 2535 Wigwam Dr CA Lic# 1001331 Class q-HAz <br /> A Ensurer gerkle net Work Comp# NBUWC0133392 <br /> T ICC Technician's Name <br /> O Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area <br /> (I.e.87 piping sump, Tank Size Chemicals Stored Currently Date UST <br /> 91 feek cletecter,UDC tit,etc.} <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> L <br /> El Approved pproved with conditions ❑ Disapproved <br /> A A, ,bment With Conditions) n <br /> N Plan Reviewers Name e ��(3/JV` -K <br /> 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: "1 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 /> 19 <br /> Applicanrs Si nature C 7e Title Office Manager Date 12/15/15 <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 Contractors -Carrie Miller TITLE Office Manager PHONE# 209.461-6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton CA 95205 <br /> SIGNATURE r4x.14, <br /> DATE 12/15/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />