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• • <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> SAN JOAQUIN COUNTY RE6EIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 MAR 10 2017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK EN1,°ir ONtvIENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT ra,Z-m?-j 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# Megan Mitchell <br /> A Flame Mini Mart 209-461-6337 <br /> C Facility Name Phone# <br /> 1 Address 1301 W.Kettleman Lane Lodi Ca 95240 <br /> L <br /> TCross Street <br /> Y Owner/Operator Bill Phone# 209-814-3581 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205CA 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 /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ErApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name kwo^ Date -.�-1 130��- <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: '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: "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 /> Applicants Signature // Title Office Assistant Date <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 Megan Mitchell TITLE Office Assitant PHONE# 209-46 ,V <br /> ED <br /> ADDRESS 2535 Wigwam Dr Stockton CA <br /> 95'2'0-5/ �j� MBAR 6 1 <br /> SIGNATURE W 2 i'ele&/GQ.('.ti DATE ' <br /> F0NMENTAL <br /> H DEYMTMENT <br /> EH230038(revised 12-11-15) 2 <br /> j <br />