Laserfiche WebLink
SAN JOAQUIN E Environmental 'RECG �/ c IV <br /> _._ C O U N T R <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> JUL 01 2022 <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT; TYPE BELOW: PERMIT/SERVICES <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller (209) 461 -6337 <br /> C Facility Name UNFI Phone # 209-931 -7431 <br /> I <br /> L Address 1990 Piccoli Road Stockton <br /> I Cross Street <br /> T <br /> Y Owner/Operator Keith Sample Phone # (209) 327 -2053 <br /> C Contractor Name Elite IV Contractors Phone # (209) 461 =6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class A <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> T <br /> T ICC Technician' s Name Expiration Date <br /> 0 <br /> R ICC Installer' s Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i. e. 97 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 (S t achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORD TH 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 (� Office Manager ir ` Title gDale 7/01 /2022 <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 Carrie Miller TITLE Office Manager PHONE # (209 ) 461 -6337 <br /> ADDRESS 2535 Wigwam �Dr Stockton , Ca 95205 <br /> SIGNATURE i � DATE 7/ 1 /22 <br /> I <br /> i <br /> 2 of 6 j <br />