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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 JAN 3 0 2019 <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 /> O TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan M 209451-5337 <br /> A925.783-6102 <br /> C Facility Name chevron Phone# <br /> I <br /> L Address 25551 Hwy 99 Acampo Ca 95220 <br /> TCross Street <br /> Y Owner/Operator '6ny Singh Phone# 925.783-6102 <br /> C Contractor Name Elite IV Contractors Phone# 209-461.6337 <br /> O <br /> T Contractor Address 2535 Wigwam or Stockton Ca 95205 CA Lie# 1001331 Class A-HAZ <br /> R Insurer Midwest Employers Casualty Company Work Comp#BNUWC0133392 <br /> A <br /> DICC Technician's Name Expiration Date <br /> T <br /> RD ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> pe.87 pipl�9 pro.91 I.k dam a.Lee 1a,W.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved With conditions ❑ Disapproved <br /> L (Sesf Attachment With Conditions) �1 <br /> N Plan Reviewers Name a '-lam Date a -2V <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 /> WORKERS 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.- IL; <br /> 7 <br /> Applicant's 51 nature Il LrGGL T81e Office Assistant Date / ;4,& <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 StocktonCa95205 <br /> SIGNATURE Y'LOa//N �"/LG7�' OY.� DATE ?E / <br /> EH230038(revised 12-11-15) 2 <br />