Laserfiche WebLink
P� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 A:GLIVEL) <br /> APPLICATION FOR UNDERGROUND STORAGE TANK MAY 14 2015 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BEL <br /> D TANK RETROFIT D PIPING REPAIR/RETROM ❑UDC REPAIR/RETROFIT EI COLD STAR <br /> F EPA Site# Project Contact&Telephone# Kim 451-6337 <br /> A <br /> C Facility Name Flames Phone# 209 334-3233 <br /> I Address <br /> L 101 W. Kettleman Lane Lodi CA 95240 <br /> TCross Street <br /> Y Owner/Operator pie Padda Phone# 209-815-5180 <br /> C Contractor Name Elite IV Contractors Phone# <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr. CA Uc# 660076 Class ABC10 HAZ <br /> A Insurer Markel Work Comp# 07 ' 30 <br /> T ICC 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 /> (Le_87 piping sump,91 leak dettecror,UDC 1/2,�) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> A d <br /> (S tta rnent With Contions) <br /> N 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> HE 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." <br /> Applicant's Signature Title Representative 5-13/2015 <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 1V Contractors TITLE Office Manger PHONE# 209-461-6337 <br /> ADDRESS 2535 W a/m Dr.Stockton CA �j 1 <br /> SIGNATURE ` �t/ DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />