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1 <br /> i <br /> 1 <br /> SANJOAQUIN__ _ � � <br /> Environnpatl �rren) <br /> —_-- E D <br /> COUNTY _. <br /> Re <br /> r'.4 .3 t <br /> IC <br /> APPLICATION FOR UNDERGROUND STORAGE TANK APR 2 4 2019 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> 1= �lVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYP1� ELOW: - . e 5,, , _ /61 -6 <br /> t- - 1t t_ <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STAR 11 /61 -GRQb9T <br /> F EPA Site # Project Contact & Telephone # Megan M 209461 -6337 <br /> � Facility Name Waterloo Shell <br /> Phone # 209 931 -3674 <br /> I <br /> L Address 4315 E Waterloo Rd Stockton Ca 95215 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Rupi Padda Phone # 209-931 -3674 <br /> C Contractor Name Elite IV Contractors Phone # <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A-HAZ <br /> T <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> Q <br /> T ICC Technician 's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L ( e achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 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 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." / )p <br /> Applicant's Signature i Title DA CL SlOjbDate <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e. g . property owner, the party must <br /> acknowledge this 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 r� <br /> SIGNATURE DATE d ' I <br /> 2of6 <br />