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ENVIRONMENTAL HEALTH DEPARTM <br /> ISE <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 JUN 14 2019 <br /> Telephone: (209 ) 468"3420 Fax : ( 209 ) 468-3433 <br /> ENVIRONNIENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEPARTRIEN �r <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 ❑ UDC REPAIR/RETROFIT ❑ COLD STARTJEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell <br /> A <br /> C Facility Name Shell Phone # <br /> I Address 620 W Charter Way Stockton Ca 95206 <br /> L <br /> TCross Street <br /> Y Owner/Operator Suhkwinder Phone # 650-740-1718 <br /> Cr Contractor Name Elite IV Contractors Phone # 209461 -6337 <br /> 0 <br /> N Contractor Address 77717 CA Lic # 1001331 Class A-HAZ <br /> T 2535 Wigwam Dr Stockton Ca 95205 <br /> R A Insurer Midwest Employers ers Casualt Company Work Comp # BNUWC0133392 <br /> C <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 /> (Le, 87 piping sump, 91 leak detector, UDC 1/2; etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved �$pproved With conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> Mn f7 <br /> N � � <br /> Plan Reviewers Name Date c� <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 ` 4 C " Tille Office Assistant Date <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 # 209A61 "6337 <br /> ADDRESS 2535 Wigwam or Stockton Ca 95205 <br /> SIGNATURE ��Q DATE <br /> EH230038 (revised 12-11 -15) 2 <br />