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• • <br /> ENVIRONMENTAL HEALTH DEPART"RtLt <br /> -- <br /> SAN JOAQUIN COU � L, <br /> 1868 b F.NTY <br /> E. Hazelton Ave., Stockton, Califomia 95205 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 NOV 19 2055 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK NVIRONMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT HFQITIJ nCDIA raT4ACRI= <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT U UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F ERA Site# <br /> A Project Contact&Telephone# Carrie 209-461-6337 <br /> C Facility Name Knifes River <br /> � <br /> Address Phone# 20g..g6g..3132 <br /> 655 W.Clay St. Stockton CA 95206 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operatnr ,1ohn or Rod er <br /> C Contractor Name Phone# C 7" <br /> o Elite IV Contractors <br /> N Phone# <br /> Contractor Address 209-461-6337 <br /> T 2535 Wi wam Dr. CA Lic# <br /> A Insurer Barkleynet 1401331 Class A_HAZ <br /> C Work Comp# NBUWC0133392 <br /> T ICC Technician's Name <br /> o Expiration Date <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area <br /> (!.a,87 p4Mg Sump,91 leak detector,UDC 1/2.etc) Tank Size Chemicals Stored Currently Date UST <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P LJ Approved Approved with conditions Disapproved <br /> A Attachment With Conditions) <br /> N Plan Reviewers Name c �2�// j i <br /> 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 /> THAT NIES THE FOLLOWING: 'I CERTIFY <br /> T HE PERFO MANCE OF THE WORK OR WHICH THIS ERMIMIT IS ISSUED,I SHALL EMPLOYWORKES COMPENSATION LAWS OF CALIFORNIA,' CONTRACT 'S HIRING ORING P RSONS SUBJ CTGNATURERTO WO KERS COMPENSATION LAWS <br /> OF CALIFORNIA." ///� <br /> ApplicanYsSignature C�� ,)4&" Title Office Manager Date 11/19/15 <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/Elite IV Contractors TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton CA 95205 <br /> SIGNATURE_ C 7ee&,, DATE 11/19/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />