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r 2,4 15 08: 58a Elite Iv Contractors Inc 2094616342 P. 1 <br /> I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 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 EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Kim White 461-6337 <br /> � Facility Name Knife River Phone" 209-969-3132 <br /> I <br /> L Address 655 W. Stockton <br /> I Cross Street <br /> T <br /> Y Owner/Operator John Phone# 969-3132 <br /> o Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> T Contractor Address 2535 Wigwam Dr CA I_ic# 660076 ClassA,B,C-10 HAZ <br /> A Insurer Markel Work Comp# MWC0070230 <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 /> (i.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 El Disapproved <br /> L A chment 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 AGENT'S 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." //>> AA ••�� <br /> Applicant's signature Cam Wl � r((e Office Manager Date 3/19/15 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EMD 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 TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwams Dr.Stockton <br /> SIGNATURE i"��'Gt'�&", DATE 3/19/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br /> Received Time Mar, 24, 2015 11 :20AM No. 8393 <br />