Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVEL <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 2 8 2015 <br />APPLICATION FOR UNDERGROUND STORAGE TANkNVIRONMENTAi. <br />RETROFIT OR PIPING REPAIR PERMIT Tu 0,4"r -^IT <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 <br />EPA Site # <br />Project Contact & Telephone # Carrie Miller 461-6337 <br />A <br />C <br />Facility Name Waterloo Shell <br />Phone # 209-931-3674 <br />I <br />L <br />Address 4315 E. Waterloo Rd Stockton <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator Rupi Padda <br />Phone # Cel # 209-914-8735 <br />C <br />O <br />Contractor Name Elite IV Contractors <br />Phone # 209-461-6337 <br />Contractor Address 2535 Wigwam Dr. <br />CA Lic # 1001331 Class A - HAZ <br />T <br />R <br />Insurer Markel <br />Work Comp # MWC0070230 <br />A <br />T <br />T <br />ICC Technician's Name <br />Expiration Date <br />Q <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />❑ qlApproved ❑ Disapproved <br />P <br />Approved with conditions <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />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 />C441, <br />Applicant's Signature Title Office Manager Date 9/18/15 <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 Elite IV Contractors TITLE Office Manger PHONE # <br />25N Wigwam Dr. Stockton CA <br />SIGNATURE <br />EH230038 (revised 07-17-2014) <br />2 <br />209-461-6337 <br />9/18/15 <br />