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FILE COPY <br /> ENVIRONMENTAL HEALTH DEPAVf- ' R! <br /> �A I- - - <br /> SAN JOAQUIN COUNTY ' � . <br /> 1868 E. Hazelton Ave., Stockton, California 95205 JUL 1 8 2017 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TlWRONMENTAL HEAL`"; <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT O UDC REPAIRIRETROFJT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan 209-461-6337 <br /> A <br /> C Facility Name US Gas I Phone# 209-465-8979 <br /> � Address 749 E Dr. Marten Luther King Blvd <br /> TCross Street <br /> Y Owner/Operator Johnny I Phone#209-465-8979 <br /> c Contractor Name Elite IV Contractors Phone# <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 sass q-FIAZ <br /> A Insurer Midwest Employers Casualty Company I work comp#BNUWC0133392 <br /> C ICC Technician's Name Expiration Date <br /> T <br /> O <br /> R ICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> OA.87 piping sump,91 leak detedm,UDC 112,etc) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name liPi�t/' I`1VV(JL�CLt� Date 7� //7 <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 AGENTS 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: 9 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 lwewl lvitchpu Tws Date <br /> 7/1712017 <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 95905 <br /> SIGNATURE Metah Mrtcheu DATE 7/17/2017 <br /> EH23003B(revised 12-11.15) 2 <br />