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ENVIRONMENTAL HEALTH DEPARTMENT _ <br /> SAN JOAQUIN COUNTY ,it�/E <br /> 1868 E. Hazelton Ave., Stockton, California 95205 MAS, 3 0 nl1 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENvjRCN EN �N <br /> -f T <br /> RETROFIT OR PIPING REPAIR PERMIT HEIPUTH ' <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Me an 209-461-6337 <br /> A <br /> C Facility Name Charter Way Chevron Phone# 209_465_3440 <br /> 1 Address 508 W Charter Way Stockton Ca <br /> TCross Street <br /> Y Owner/Operator Phone# 209-465-3440 <br /> o Contractor Name Elite IV COntraCtOfS Phone# 209-461-6337 <br /> T Contractor Address warn Dr CA Lic# 1001331 Class <br /> A Insurer MidweStWork comp#BNUWC0133392 <br /> TICC Technician's Name Expiration Date <br /> ' <br /> ICC Installers Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector.UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions I..I Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name QW ^ � /^•� <br /> GIL A�� Date_ � - a� <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 Title Date_. 1 1 <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 2.535 Wmqwqm nr Stockton Ca 95205 <br /> \ <br /> SIGNATURE i'/G+7.QG„♦L DATE_ ��>II <br /> 61 <br /> 1 <br /> EH230038(revised 12-11-15) 2 <br />