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ENVIRONMENTAL HEALTH DEPARTMWEIVEL) <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 NOV 0 9 2615 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK WFAITw ncDA RfiP:ftI P <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 REPAIRIRETROFIT D UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# T 209461-6337 <br /> A Facility Name Phone# <br /> C ty Laths Shell 209-403-3859 <br /> I Address 16500 Harlan Rd. Lathrop, CA 95330 <br /> L <br /> YCross Street <br /> Y Owner/Operator Chris Phone# <br /> o Contractor Name Elite IV Contractors Phone# <br /> T Contractor Address 2535 Wigwam Dr.Stockton GA Llc# 1001331 Class A_HAZ <br /> A Insurer Barkle net I Wont ComP# NBUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 pimp surrp,91 IN&dote=.UDC 1/2.Mj Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved 12reApproved With conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <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: "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 /> WORKERS COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signati C 714Tie® Office Manager ram 1119115 <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# 209461-6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton , CA 95205 <br /> SIGNATURE NaA41 DA-IE 11/9115 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />