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SAN . J O A O U I N Environmental Health Departrnent <br /> -- - C O U N T Y, - __ - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT D PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209 - 461 -6337 <br /> � <br /> Facility Name Ag S anos Jet Center Phone # 209 - 993 -2481 <br /> � Address 4800 S Airport Way Stockton Ca 95206 <br /> 1 Cross Street <br /> T <br /> Y OwnerlOperator Thomas Phone # 209- 993 -2481 <br /> o Contractor Name Elite IV Contractors Phone # 20g. 461 .6337 <br /> T Contractor Address 2535 gwam CA Lic # 100133 Class A- HAZ <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 /> (.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name � .lt l� S .� 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 9LPAR ENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR <br /> WHI ri 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 CALI ORNIA." /CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WOR FORl) CH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 0 / / �1 <br /> , l <br /> Applicant's Signatur �� ? / � ~ — Title Office Assistant Date 4 � <br /> f BILLING INFORMATION : <br /> Indicate the respinsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Megan Mitchell TITLE Office Assistant PHONE # 209461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 1 <br /> SIGNATURE DATE <br /> 2of6 <br />