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I � 0 <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 E .,,.:." <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />D TANK RETROFIT a PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT 0 COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone# Megan 209-461-6337 <br />A <br />C <br />Facility Name EI Dorado Shell Phone# 209-943-1311 <br />I <br />Address 2320 El Dorado Shell Stockton Ca 95204 <br />L <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator Bob Lutz <br />Phone# 209-943-1311 <br />C <br />0 <br />Contractor Name Elite. IV Contiactois <br />Phone# 209-461-6337 <br />IN <br />T <br />Contractor Address <br />253" igwam Dr Stockt n CZ9 <br />CA Lic# 1001331 Class <br />A- <br />R <br />A <br />insurer Midwest Employers Casually Company <br />Work Comp#HAZ- <br />BNUWQQ13M <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />0 <br />R <br />ICC Installers Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 07 piping sump, 91 leak detector, UDC 1f2. etc.) <br />T <br />A <br />N <br />K <br />P, <br />El ApprovedApproved With conditions ❑ Disapproved <br />�A�achment <br />L <br />'tachm With Conditions) <br />A <br />N <br />Plan Reviewers Name'Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANeE 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: *1 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 />WORKERS 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 WORKERS COMPENSATION LAWS <br />OF CALIFORNIA." <br />Appliceirif s SignaturewAaagl- 2&�" TM ce Assistant -D -t- 211912018 <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 Megan Mitchell TITLE ...OfriCe Assistant PHONE # 209-A61-6337 <br />EH230038 (revised 12-11-15) 2 <br />