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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY _ _ <br /> 1868 E. Hazelton Ave., Stockton, California 95205 RECEIVED <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> SEP 17 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOIMEAt TH p1-1ARTMENT <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan M 209-461-6337 <br /> A209-649-8171 <br /> C Facility Name River Point Marina Phone# <br /> 1 Address 4950 Buckly Cove Stockton Ca 95219 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Andrew Phone# 209-649-8171 <br /> Contractor Name Elite IV Contractors <br /> O Phone#209-461-6337 <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 Class A-HAZ <br /> T <br /> R Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> A <br /> T <br /> T ICC Technician's Name Expiration Date <br /> Q <br /> R ICC 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 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P LJ Approved Approved with conditions ❑ Disapproved <br /> L (See ttachment With Conditions) <br /> A • ?-c01� <br /> N Plan Reviewers Name 1/ W Date I V <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." <br /> Applicant's Signature Title Office Assistant Date 9/17/2018 <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 952,,055 �� �� <br /> SIGNATURE �7!'Ge%(.C%/l� DATE 9/17/2018 <br /> 61 <br /> EH230038(revised 12-11-15) 2 <br />