Laserfiche WebLink
SAN 1QAQUIN <br />.-COUNTY <br />Environmental Health Department <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 780 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact &Telephone It Deborah Jones / Administrative Assistant <br />� <br />Facility Name Atwal Inc / Plaza Liquors <br />Phone # (209) 368-0127 <br />I <br />L <br />Address 800 S Cherokee Lane Lodi, CA 95240 <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator Atwal Inc <br />Phone #(209) 3M01 <br />C <br />0 <br />Contractor Name Elite IV Contractors <br />Phone #(209) 461-6337 <br />N <br />T <br />Contractor Address 2535 Wigwam Drive Stockton, CA <br />95205 <br />CA Lic # 1001331 Class A-Hazmat <br />R <br />A <br />Insurer Midwest Employers Casualty Company <br />Work Comp # BNUWC0133392 <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />0 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC Wo etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved <br />pproved with conditions ❑ Disapproved <br />L <br />A <br />(S a <br />ttachment With Conditions) <br />N <br />Plan Reviewers Name <br />Date OG lao 174,7,1 <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 FPR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signetu Title <br />Administrative Assistant Date 5/21/2021 <br />v � 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 Deborah Jones <br />TITLE Administative Assistant PHONE# (209) 461-6337 <br />AQDRESS 2535 Wigwam Drive Stockton, CA 95205 <br />d <br />SIGNATOR <br />2ofG <br />TE 5/21!2021 <br />