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ENVIRONMENTAL HEALTH DEPARTOWEIVED <br /> SAN JOAQUIN COUNTY MAR 17 2015 <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL <br /> NcA'TI-Ji r) DADTAACkrr <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 REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Kim White (209)461-6337 <br /> A <br /> C Facility Name California Stop Phone# 209-406-1484 <br /> I Address 2224 Manthey Rd. Stockton, CA <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Tim Phone# 209-406-1484 <br /> o Contractor Name Elite IV Contractors Phone# <br /> T Contractor Address 2535 Wigwam Dr. Stockton, CA CA Lic# 660076 Class ABC-10HAZ <br /> R Insurer Markel <br /> A Work Comp# MWC0070230 <br /> C <br /> T ICC Technician's Name Expiration Date <br /> o I ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> It T <br /> t- + <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se' Attachment With Conditions) <br /> A C <br /> N 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 /> Applicant's Signature Title Office Manager 3/17/15 <br /> Date <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 /Carrie Miller TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton, CA <br /> SIGNATURE (/�Ai1/O, 71L&A, DATE 3/17/15 <br /> EH230038(revised 08/1/11) <br /> 2 <br />