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1 <br /> • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY ECEIVED <br /> 1868 E. Hazelton Ave., Stockton, Califomia 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 1=E B O 12017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT 0 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 Lathrop Shell Phone# 209-983-0381 <br /> 1 Address 16500 S.Harlan Rd Lathrop Ca 95269 <br /> L <br /> TCross Street <br /> Y Owner/Operator Chris Arbabian Phone# 209-983-0381 <br /> c Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 <br /> T CA Lic# 1001331 Class A-HAZ <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> C <br /> T ICC Technician's Name Jarod B Expiration Date 11/3/18 <br /> Q <br /> R ICC Installer's Name Joe B Expiration Date 11/3/17 <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 /> 10,000 Unleaded Unknown <br /> T <br /> A 10,000 Premium Unknown <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( ttachment With Conditions) <br /> A ����a <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR E WITH SAN ICAQUIN 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 ISS,ufD,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACT S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'i CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHI THI PE T IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> .APP icants Signature Lk n,, Office Assistant Date 2/1/2017 <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# 209-461-6337 <br /> ADDRESS 253 Wi wam Dr Stockton Ca 95205 <br /> SIGNATURE DATE 2/1/2017 <br /> EH230038(revised 12-11-15 2 <br />