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ENVIRONMENTAL HEALTH <br /> SAN JOAQUIN COUNT k <br /> 1868 E. Hazelton Ave., Stockton, Califomia 95205 1 0 17 <br /> Telephone: (209)468-3420 Fax: (209)468-3433LT1 <br /> APPLICATION FOR UNDERGROUND STO TAL <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT ©PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Facility Name Gas Depot <br /> Phone# 209-825-0332 <br /> 1 Address 1330 E Yosemite Ave Manteca Ca 95336 <br /> L <br /> TCross Street <br /> Y Owner/Operator Kevin Hur Phone# <br /> C Contractor Name Elite IV ContractorsPhone# 209-461-6337209-825-0332 <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 100331 Class A-HAZ <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> TICC 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 detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> IN <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date -S_10! t:4. <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 /> 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 /> [Applicants Signature Tale Office Assistant Date 5/08/2017 <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 Assistant PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca'95/20055- / <br /> SIGNATURE W�f a—yi wlel DATE 5/812017 <br /> EH230038(revised 12-11-15) 2 <br />