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ENVIRON MENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />Me an 209-461-6337 <br />� <br />Facility Name Waterloo Shell <br />Phone # 209-914-8735 <br />� <br />Address 4315 E Waterloo Rd Stockton Ca 95205 <br />TCross <br />Street <br />Y <br />Owner/operator Rupi Padda <br />Phone# 209-914_-8735 <br />Contractor Name Elite IV Contractors <br />Phone # 209-461-6337 <br />0 <br />N <br />T <br />_ <br />Contractor Address25,35 Wigwam Dr Stockton Ca 9520�CA <br />Lic # <br />Class <br />A-HAZ <br />A <br />insurer Midwest Em la ers Casualty Company <br />work comp # BNUWC0133392 <br />G <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />leak detector, UDC 12stalled <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions <br />❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />_ <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 <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE <br />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 <br />'� /?� �' <br />Signature !�2`"�'�� '�' Title ()ffarp_ ACC,j$tant <br />r} 1 <br />Date <br />L/ <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 MPcian Mitchell TITLE Office Assistant PHONE # 209-461-63337_ <br />ADDRESS 2535 <br />Dr Stockton Ca 95205 <br />SIGNATURE ZG,�¢CGiL rrl�.GL/t DATE <br />EH230038 (revised 12-11-15) <br />