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tNVIR0N !-N I AL r1SAL I H Vt K I M�, -4 <br /> AN JOAQUIN COUN ()+ <br /> 9868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone. (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPtRES 180 DAYS FROM THE APPROVAL DATE_ INDICATE PERMIT TYPE BELOW. <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT Q UDC REPAIRIRETROFIT o COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# I o 4- ;! -�e'3 <br /> A <br /> Facility Name Phone# 209-366-7332 <br /> � tY Casttxr#9094 <br /> I Address 2680 Re nolds Ranch Parkway <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Costco Phone# <br /> o Contractor Name Elite IV Contractors Phone# <br /> N <br /> T Contractor Address 2535 Wgmm Dr Stockton CA Lic# 660076 Ctass ASC10 HAZ <br /> A Insurer Markel Work Comp# MWC0070230 <br /> cICC Technician's Name Expiration Date <br /> T <br /> ° ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Sime Chemicals Stored Currently Date UST <br /> (Le.87}Aping sump.91 teak detector,UDC irz,etc.) installed <br /> T <br /> A <br /> N <br /> K <br /> I <br /> P Approved pproved with conditions Disapproved <br /> L chment With Conditions) ,r <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULA`IIONS OF SAN <br /> JOAQUIN COUNTY, ENVI ENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT S SIGNATURE CERTIFIES THE FOLLOWING: "1 CER'i IFY THAT IN <br /> E PERFORMANCE OF E ORK FOR WHtC.H THIS PERM IT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS'I Q BECOME SUBJECT'TO <br /> WORKEWS COMPEltS EON WS OF CALIFORNIA." RACTOWS HIRING OR SLOCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFO AAN OF THE WORK FOR WHI PERMIT Is ISSUED, HALL EMPLOY PERSONS SUBJECT TO WORKER S COMPENSATION LAWS <br /> OF CALIFORNIA." i <br /> Applicarift Signature L t Y! T, t Date <br /> r <br /> BILLING I FORMATION: <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 appplicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Elite IV Contractors TITLE O Ce Manager PHONE# 2Q9-461-6337 <br /> ADDRESS 2535 warn Dr.Stockton CA 9fi2j& <br /> siOr>IATuizr_ �, DATE 4/22/15 <br /> 77�t <br /> EH230038(revised 07--17-2014) <br /> 2 <br />