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ENVIRONMENTAL HEALTH DEPAR1114PMIVED <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, Califol-nia 95205 APR 3 0 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 E-NVI RON MENTAL, <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 /> D TANK RETROFIT 0 PIPING REPAIR(RETROFIT o UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# —Praject Contact&Telephone# Kim 461-6337 <br /> A <br /> C Facility Name Super Stop Phone# <br /> IAddress <br /> L 290 N. Main St <br /> Cross Street <br /> T <br /> Y Owner/Operator Sun Phone# 209-815-5180 <br /> 0 Phone# <br /> C Contractor Name Elite IV Contractors <br /> N <br /> T Contractor Address 2535 Wigwam Dr. CA Lic# 660076 Class ABC1 0 HAZ <br /> R <br /> A Insurer Markel Work Com # 10 <br /> T ICC Technician's Name Expiration Date <br /> 0 <br /> R ICC Installer's Name Expiration Date Date UST <br /> Tank system work area Tank Size Chemicals Stored currently <br /> (I.e.87 oping sump,91"k detWor,UDC 1d2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> Approved with conditions Disapproved <br /> P E Approved L7 <br /> L (See Attachment VVAh Conditions) <br /> A <br /> N <br /> I Plan Reviewers Name U CA41mct n 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." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCFIOF 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. I-/ Date <br /> (l.", Tit <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 Gontractors TITLE office Manger PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam DfStockton CA <br /> y jr, DATE IJ <br /> SIGNATURE -z <br /> EH230038(revised 07-17-2014) <br /> 2 <br />