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ENVIRONMENTAL HEALTH DEPARTMEI (;Lj LL <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 MAR 3 A 2016 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK 1-IrArTLJ <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 209461-6337 <br /> G Facility Name Waterloo Shell Phone# 209-931-3674 <br /> 1 Address <br /> L 4315 E.Waterloo Rd Stockton CA <br /> I Cross Street <br /> T <br /> Y Owner/Operator Rupi Padda Phone# 209-914-8735 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> o <br /> T Contractor Address 2535 Wigwam Dr Stockton CA CA Lic# Class <br /> A Insurer Midwest Employers Casuality Work Comp# 13NUWC0133392 <br /> c <br /> T ICC Technician's Name Expiration Date <br /> }} <br /> Q <br /> R ICC Installer's Name Expiration Date I <br /> Tank system work area Tank Size Chemicals Stored Currently <br /> Date UST I <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> #1 <br /> 1 <br /> P ❑ Approved 14 Approved with conditions "Ll Disapproved <br /> L (See Attachment With Conditions) <br /> A `^ // �� <br /> N Plan Reviewers Name ' Date Ll I _I uo <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 Tille Office Manager Date 3130/16 <br /> BILLING INFORMATION: <br /> I <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 Elite IV Contractors -Carrie Miller TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton CA <br /> t <br /> SIGNATURE �����-o WWA41- DATE <br /> 3/30/16 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />