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ENVIRONMENTAL HEALTH DEPARTMP�, <br /> SAN JOAQUIN COUNTY RtzuBVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 JAN 17 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <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# Megan Mitchell 209-461-6337 <br /> A <br /> O Facility Name Waterloo Shell Phone# 209-931-3674 <br /> 1 Address 4315 Waterloo Rd Stockton Ca 95205 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Rupi Padda Phone# 209-931-3674 <br /> C Contractor Name Megan Mitchell Phone# 209-461-6337 <br /> O <br /> N <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUCW0133392 <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 /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approvedl �J__Approved with conditions ElDisapproved <br /> L <br /> A �, / .(See Attachment With Conditions) , <br /> N Plan Reviewers Name s ' - Date I Z. <br /> �. <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULA71ONS 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 PER IT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CO TR CTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFOR NNE OF THE WgRK FOR yVOICH 'HI ERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." _ I fG � t <br /> �� ?_Office Assistant 1/3/2017 <br /> Applicant's Signature Date <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 Megan Mitchell - TITLE Office Assistant PHONE# 20-461-6337 <br /> ADDRESS 2535,Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE i' , DATE 11/15/2016 <br /> EH230038(revised 12-11-1:5) 2 <br />