Laserfiche WebLink
REGLIVEL <br />tNVIRONMENTAL HEALTH DEPARTME�NT 0 6 2015 <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 ENVIRONMENTAL <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 HFAITw ncPAoTmFNT <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />?OFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REP RETROFIT 0 UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Carrie 209-461 -M7 <br />A <br />C <br />Facility Name Phone# 209-823-7628 <br />1 <br />L <br />Address (0 Anz 4 4 1 1 <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator Quik Stop Markets <br />Phone# 1800-972-0982 <br />C <br />0 <br />Contractor Name Elite IV Contractors <br />Phone # <br />N <br />T <br />Contractor Address 2535 Wigwam Dr. <br />CA Lic # 1001331 Class A- HAZ <br />R <br />Insurer Berkleynet Wog comp# NBUWC0133392---- <br />A <br />C <br />T <br />ICC Technician's Name Expiration Date <br />0 <br />ICC Installer's Name Expiration Date <br />Tank system work area <br />Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />fm 87 pipirtl; Knp, 91 leak deWor, UDC 1/2. etc.) <br />T <br />A <br />N <br />K <br />P <br />D Approved Approved with conditions ❑ Disapproved <br />L <br />(S Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Mauzo Date--jLjj-- a-01 <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 COMPENS LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFOR E OF THE WORK FOR WHICU TIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Office Manager 11/6115 <br />Applicants Sigrotureft UL 'i rine— Date <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 billinge V Contractors slinature and date below. <br />KIALSP Carrie Miller - litTITLE Office -Manager PHONE # 209-461-6337 <br />EH230038 (revised 07-17-2014) <br />K <br />