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-FNVIR4N9ENTAL 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 100 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # Me an 209-461-6337 <br />� <br />Facility Name Waterloo Shell Phone # 209-914-8735 <br />1 <br />Address 4315 E Waterloo Rd Stockton Ca 95205 <br />I <br />T <br />Cross Street _ <br />Y <br />Phone # 209-914-8735 <br />owner/operator RUpI Padda _ _ <br />o <br />Contractor Name Elite IV Contractors <br />Phone# 209-461-6337 <br />T <br />_ <br />Contractor Address 2535Wialtlllarn DrStockton_C CA Lie # Class A-HAZ <br />RInsurer <br />A <br />Midwest Em to ers CasualtyCom an <br />Work Comp # BNUWC0133392 <br />T <br />r <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />_— <br />Expiration Date <br />Tank system work area <br />-- <br />Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />(ie. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />T <br />-- <br />A <br />N <br />K <br />P <br />Ll Approved Approved with conditions ❑ Disapproved <br />L <br />(Sae 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 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 />Annllcant's Sianature __._Title..---___Date^li.;AI��_Z 1I <br />u <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_Me_gan Mitchell TITLE Office Assistant PHONE#___209-461-_63S_L___ <br />ADDRESS 2535 Wigwam Dr <br />^Stockton Ca 95205 <br />SIGNATURE_-- {:� �rl� DATE_("/ G j� <br />EH230036 (revised 12-11-15) <br />