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ENVIRONMENTAL HEALTH DEPARTMRECEIVED <br /> SAN JOAQUIN COUNTY JAN 28 2016 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK HEALTH DEPARTMENT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie 209)-461-6337 <br /> A <br /> C Facility Name Flag City Chevron -Stars Holding CO LLC Phone# <br /> Address <br /> 6421 Capitol Ave Lodi, CA 95242 <br /> I Cross Street <br /> T --- <br /> Y Owner/Operator Que Phone# <br /> 209-461-6337 <br /> C Contractor Name Elite IV Contractors Phone# <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr. Stockton CA CA Lic# 1001331 Class A-HAZ <br /> R Insurer <br /> A Midwest Employers Casuality Company Work Comp# gNUWC0133392 <br /> TICC Technician's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (t.e.87 piping sump,91 leak detector.UDC 1;2.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P P, Approved pproved with conditions L_� Disapproved <br /> L ment With Conditions) <br /> A <br /> N Plan Reviewers Name " Date <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 ..Office Manager Date 1/28116 <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 Carrie Miller - Elite IV Contractors TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton <br /> SIGNATURE lllDATE 1/28/16 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />