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ENVIRONMrNT AL HEAL11i C) LIPARTMENT <br /> SAN JOAQUIN COUNTY ° . A <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 r_ _ EV <br /> Telephone : ( 209 ) 468 - 3420 Fax : ( 209 ) 468-3433 JAN 2 2 2019 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK , , ., .. � � \ <br /> " ' a 'tiiAt< <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> T I-t �1 f?T Ii <br /> i <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 # Project Contact & Telephone # Megan M 209-461 -6337 <br /> A <br /> C Facility Name Eugenie Valdez Phone # 209 -982-0897 <br /> I <br /> L Address 8125 S EI Dorado St French Camp Ca 95231 <br /> TCross Street <br /> Y Owner/Operator Eugenie Valdez Phone # 209-982-0897 <br /> C Contractor Name Elite IV Contractors Phone # 209-461 -6337 <br /> 0 <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 /> TICC Technician 's Name Expiration Date <br /> RICC 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 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N <br /> Plan Reviewers Name r ► V `L��L 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 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 711kTitle Office Assistant Date <br /> Ll <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 /> SIGNATUREyl leo; -z f7.Qjo� DATE <br /> EH230038 (revised 12- 11 -15 ) 2 <br />