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0 <br />0 <br />ENVIRONMENTAL HEALTH DEPART#/I ;* <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 J UJ L I <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK ' rr74 ��T <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Megan 209-461-6337 <br />C <br />Facility Name Quick Shop <br />Phone # 209-345-1689 <br />I <br />L <br />Address 2072 Yosemite Ave Manteca Ca 95337 <br />I <br />Cross Street <br />T <br />Y <br />- <br />Owner/Operator Pete <br />Phone # 209-345-1689 <br />o <br />Contractor Name Elite IV Contractors <br />Phone # 209-461-6337 <br />N <br />T <br />Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A-HAZ <br />A <br />Insurer Midwest Employers Casualty Company <br />work Comp # BNUWC0133392 <br />T <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector. UDC 12, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />SeAttachipient With Conditions) <br />N <br />/ <br />1 <br />Plan Reviewers Name_4�: 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 AGENTS 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." <br />Applicant's Signature Megan Mrtchea Tice Office Assistant Dale 7/10/2017 <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 Office Assistant PHONE # 209-461-6337 <br />ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br />SIGNATURE Mein Mrtchea DATE 711012017 <br />EH230038 (revised 12-11-15) <br />