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• <br />ENVIRONMENTAL HEAL <br />L] <br />TH DEPART T, <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 JAN 19 2016 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />NVOONMEWA <br />APPLICATION FOR UNDERGROUND STORAGE TANKf'�TP.I>z�, , :r <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Terry Masters 209-461-6337 <br />A <br />C <br />Facility Name Hammer Lane Oil Phone # 209-478-9293 <br />I <br />Address 3304 W. Hammer Lane Stockton CA <br />L <br />TCross <br />Street <br />Y <br />Owner/Operator Mike furm <br />Phone # 209-992-1415 <br />C <br />O <br />Contractor Name Elite IV Contractors <br />Phone # <br />T <br />Contractor Address 2535 Ngwam Dr. CA Lic # 1001331 Class A- Haz <br />A <br />Insurer Midwest Employers Casuali Com ny <br />Work Comp# BNUWC0133392 <br />TICC <br />Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 pip'ng sump, 21 leak detector, UDC 112. etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved -Approved with conditions 10 Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N, <br />Plan Reviewers Name -'S Date �) C <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: "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 />�� <br />Applicant's Signature€ Title Office Manager Date 1118116 <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 Carrie Miller TITLE Office Manager PHONE # 209-461-6337 <br />ADDRESS 2535 Wigwam Dr. Stockton CA 95205 <br />SIGNATURE c .L�l Ak� DATE <br />EH230038 (revised 07-17-2014) <br />2 <br />