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�r► w <br /> ENVIRONMENTAL HEALTH DEP NT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> A+ 0 5 201? <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE fAARROWOIENT,dL HE/%LTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEP,�PTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# DEProject Contact&Telephone# Megan 209-461-6334 <br /> A <br /> G Facility Name Wilson Way Chevron Phone#209-942-2344 <br /> I Address 437 Wilson Way Stockton Ca 95205 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Paul Judge Phone#209-942-2344 <br /> C <br /> contractor Nam <br /> 0 <br /> Ca Elite IV Contractors Phone# 209-461-6337 <br /> N <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 Class A-HAZ <br /> R <br /> A insurer Midwest Employers Casualty Company Work Comp#BNUWC0133392 <br /> C <br /> T ICC Technician's Name Expiration Date <br /> 0 <br /> _R ICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump.91 leak detects.UDC IQ,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Ll Approved Approved with conditions El Disapproved <br /> L _ See Attaco;nent With Conditions) AMEN ED <br /> A r 1 <br /> N Plan Reviewers Name Date /02-/2c'17 <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: N 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 Ne an Ritche,U Title Office Assistant --Date-. 911/2017 <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 Megan Mitchell TITLE Office Assistant —PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE usW11 "i&,A0jL —DATE 9/112017 <br /> EH230038(revised 12-11-15) 2 <br />