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S n N O n Q U I N EnviroREEWED <br /> Oalt <br /> too I) OV0 <br /> AIL %3r 0 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERIIWVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELb�' F3A Tn T <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/E� UI� DE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209-461 -6337 <br /> APhone # <br /> C Facility Name North Pole Gas 209. 833 . 1416 <br /> I Address 574 W Grant Line Rd Trac Ca 95376 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator GUrvinder Sin Phone # 209m833_3416 <br /> o Contractor Name Elite IV Contractors Phone # 2n9.461 .60117 <br /> N Contractor AddressCA Lie # ooini Class <br /> T <br /> A Insurer Midwest Em to ers Casualt Com an Work Comp # gNUWC0133392 <br /> C <br /> T ICC Technician 's Name Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work areaDate UST <br /> (i.e. 87piping sump, 91leak detector, UDC 1/2, etc.) Tank Size Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS �RMITIS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." ONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR CH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature TiBe (lffiea O4RIRtAnt <br /> Date <br /> ii <br /> i <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e. g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Megan Mitchell TITLE Office Assistant PHONE # 209461 - 6337 <br /> ADDRESS 2535 Wi wam Dr Stockton C 95205 <br /> SIGNATURE, / DATE 3o <br /> 2 of 6 <br />