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0 0 <br />ENVIRONMENTAL HEALTH DEPARTVft <br />�I�'EI� <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 NOV 02, 203 <br />Telephone: (209) 468-3420 Fax; (209) 468-3433 <br />ENVIRONMENTAL <br />APPLICATION FOR UNDERGROUND STORAGE TANK wl=A1T-I ncDAlaTA4rkm <br />RETROFIT OR PIPING REPAIR PERMIT <br />ElApproved P Approved with conditions ❑ Disapproved <br />L (See Attachment With Conditions) <br />N plan Reviewers Name Date <br />3PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />1AQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br />iE PERFORMANCE OFT E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />ORKER'S COMPENS I LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY <br />1AT IN THE PERFOR Nf$E OF THE WORK FOR WHICH TLJ ERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />c CALIFORNIA.' ,I —/I i /r <br />Office Manager I0 <br />nasi <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 billinc� by signature and date below. <br />Carrie Miller - EIIte IV Contractors Office Manager NAME TITLE g PHONE # q - <br />EH230038 (revised 07-17-2014) <br />F1 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Carrie 209-461-6337 <br />A <br />C <br />1 <br />Facility Name Costco # 31 <br />Phone # 209-824-2$66 <br />Address ;) <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator Dave Zizzo <br />Phone # 209-824-2860 <br />o <br />Contractor Name Elite IV Contractors <br />Phone # 461-$337 <br />T <br />Contractor Address 2535 Wigwam Dr. <br />CA Lir # 1001331 Class A-HAZ <br />A <br />G <br />Insurer Barkleynet <br />Work Comp # NBUWG013339: <br />T <br />ICC Technician's Name <br />6cplfatlOn Date <br />R <br />ICC Installers Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 Oping sump, 91 leak deWor. UDC 112. et .) <br />Tank Size Chemicals Stored Current) Date UST <br />y <br />Installed <br />T <br />A <br />N <br />K <br />ElApproved P Approved with conditions ❑ Disapproved <br />L (See Attachment With Conditions) <br />N plan Reviewers Name Date <br />3PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />1AQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br />iE PERFORMANCE OFT E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />ORKER'S COMPENS I LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY <br />1AT IN THE PERFOR Nf$E OF THE WORK FOR WHICH TLJ ERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />c CALIFORNIA.' ,I —/I i /r <br />Office Manager I0 <br />nasi <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 billinc� by signature and date below. <br />Carrie Miller - EIIte IV Contractors Office Manager NAME TITLE g PHONE # q - <br />EH230038 (revised 07-17-2014) <br />F1 <br />