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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. HazeIton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br />F <br />A c <br />I <br />L <br />I <br />T <br />V <br />EPA Site # Project Contact & Telephone # Megan M 209 -461 -6337 <br />Facility Name JD Service Station Phone # 209-794-8993 <br />Address 9015W Walnut Grove Rd Thornton Ca 95686 <br />Cross Street <br />Owner/Operator Phone # 209 -794 -8993 <br />c <br />0 <br />N <br />T <br />R <br />A c <br />T <br />0 R <br />Contractor Name Elite IV Contractors Phone # 209-461-6337 <br />Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A_HAz <br />Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br />ICC Technician's Name Expiration Date <br />ICC Installer's Name Expiration Date <br />T <br />A <br />N <br />K <br />Tank system work area <br />(i.e. 87 plping sump, 91 leak detector. UDC 1/2, etc.) Tank Size Chemicals Stored Currently Date UST <br />Installed <br />• <br />P <br />L <br />A <br />N <br />Approved with conditions 0 Disapproved <br />(See Attachment With Conditions) <br />\ OW ,3.0 Date 0 -1 q <br />111 Approved <br />Plan Reviewers Name et elAfX. V V <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 774p 7///k&I.4/1 Title Office Assistant Date <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 2535 Wigwam Dr Stockton Ca 95205 <br />SIGNATURE 7/ylz7-zXdg <br /> <br />DATE <br /> <br />EH230038 (revised 12-11-15) 2