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ENVIRONMENTAL HEALTH DEPARTII EN <br /> SAN JOAQUIN COUNTY r!L� F' <br /> 1868 E. Hazelton Ave., Stockton, California 95205 JUL 0 3 2018 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br /> DNME T AL <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> NT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# <br /> 11 A Project Contact&Telephone# Megan M 209-461-6337 <br /> c Facility Name DKS Investments Phone# 925-960-3797 <br /> 1 Address <br /> L 9484 West Lane Stockton Ca 95210 <br /> TCross Street <br /> Y Owner/Operator Gurbeet Singh Phone#925-960-3797 <br /> C <br /> 0 Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> TICC Technician's Name Expiration Date <br /> oICC Installer's Name <br /> R 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.) <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name 12� 1 ' �'l`wDate <br /> ^ —q — (j ' <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 Tide Office Assistant Date JZ21), <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 7W44X1�11i f� DATE <br /> EH230038(revised 12-11-15) 2 <br />