Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTFECEIVED <br /> SAN JOAQUIN COUNTY OCT 15 2018 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 ENVIRONMENTAL <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 PERMIT/SERCES TH <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 REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan M 209-461-6337 <br /> A <br /> C Facility Name Plaza Liquor and Gas Phone# 209-914-8735 <br /> 1 Address 2420 W Turner Rd Lodi Ca 95242 <br /> L <br /> TCross Street <br /> Y Owner/Operator Rupi Padda Phone# 209-941-8735 <br /> C Contractor NamePhone#209-461-6337 <br /> O Elite IV Contractors <br /> N <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 Class A-HAZ <br /> R Insurer Midwest Employers Casualty Company <br /> A Work Comp#BNUWC0133392 <br /> T <br /> T ICC Technician's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC V2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Vf�� r' 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 Assistant Date 10/15/2018 <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 M TITLE Office Assistant PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 9,5520055 <br /> SIGNATURE W1i DATE 10/15/2018 <br /> EH230038(revised 12-11-15) 2 <br />