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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECOVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 MAY 0 9 2016 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> ENVIRONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK PERMIT/SERVICES <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# Terry Masters 209-461-6337 <br /> c Facility Name AGS anos Jet Center Phone# 209_903 2481 <br /> I Address 4800 S Airport Way Stockton CA <br /> L <br /> I Cross Street <br /> Y Owner/Operator Tara Hagopian Phone#209-993-2481 <br /> GContractor Name Elite IV Contractors Phone# 2pg-461-6337 <br /> 0 <br /> N Contractor Address CA Lic# 1001331 Class A-HAZ <br /> R Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tanks stem work areaDate UST <br /> Y ETankze Chemicals Stored Currently Installed <br /> (I.e.87 piping sump,91 leak detector,UDC 112,etc) <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) ( � / <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 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 /> Appllcenrs Signature <br /> 7i8a (lffire Assistant <br /> Data 5/9/2016 <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 Of CeP &SSMtan PHONE#-209-461--6337— <br /> ADDRESS <br /> 209 46 6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> DATE 5/9/2016 <br /> SIGNATURE <br /> EH230038(revised 07-17.2014) <br /> 2 <br />