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EIVED <br /> ENVIRONMENTAL HEALTH DEPARTM JAN 29 2016 <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, Califomia 95205 ENVIRONMENTAL <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 HEALTH DEPARTMENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <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 REPAIRIRETROFIT D COLD STARTIM UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 209-461-6337 <br /> A Phone# <br /> C Facility Name Costco <br /> L <br /> Address 1616 E. Hammer Lane Stockton CA <br /> I Cross Street <br /> T phone# 209.475-9180 <br /> v Owner/Operator Costco <br /> Phone# 209.461-6337 <br /> C <br /> Contractor Name Elite IV Contractors <br /> N CA Lic# 1001331 Class A-HAZ <br /> T Contractor Address 2535 Wi am Dr.Stockton <br /> R Insurer Midwest Employers Casuality Comapany work comp# <br /> A Expiration Date <br /> G ICC Technician's Name <br /> T Expiration Date <br /> D ICC Installer's Name <br /> R Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 plying sump,91 leak eetecmr,UDC 112,etc.) <br /> T <br /> A <br /> N <br /> K <br /> P <br /> ❑ Approved TSF'Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) z <br /> A -�C () A'1 �^` �n 011 f� Date ✓^i <br /> N Plan Reviewers Name n <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 SUBJECTTO <br /> WHAT INR HE COMPENSATION LAWS OF <br /> OF HE WORK PDR WHICH OT IS PERMIT IS HIRING <br /> ISSUED, SHALLOEMPLOY PERCTING SONS SUBJECT TO WORKERTURE CERTIFIES THE S CO COMPENSATION LAWS <br /> OF CALIFORNIA' Office Manager Data 1129116 <br /> Applicant's Signetule <br /> 718a <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. 209-1461-6337 <br /> NAME Elite IV Contractors -Carrie Miller TITLE Office Manager PHONEI, <br /> ADDRESS 2535 Wigwam Dr. Stockton , CA <br /> 1129116 <br /> DATE <br /> SIGNATURE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />