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ENVIRONMENTAL HEALTH DEPART F.I�' D <br />SAN JOAQUIN COUNTY AUG 6 Z 2096 <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONJ4ENTAL HEALTH <br />PERMIT>vERAOES <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 <br />EPA Site # <br />Project Contact & Telephone # Megan MitChell <br />C <br />Facility Name Flag City Shell <br />Phone # 209-461-6337 <br />1 <br />Address 6437 Banner St Lodi Ca <br />TCross <br />Street <br />Y <br />Owner/Operator Rupi Padda <br />Phone# 209-941-8735 <br />C <br />O <br />Contractor Name Elite IV Contractors <br />Phone # 209-461-6337 <br />N <br />Contractor Address 2535 Wigwam Dr Stockton Ca <br />CA Lic # 1001331 Class A-HAZ <br />A <br />Insurer Midwest Employers Casualty Company <br />work comp # BNUWC0133392 <br />cICC <br />T <br />Technician's Name <br />Expiration Date <br />RICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved CIPApproved with conditions ❑ Disapproved <br />L'41 <br />(chment With Conditions) <br />A <br />�� <br />N <br />// <br />Plan Reviewers NameDate <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 />-� <br />e,,,,u,. V. cl,,,, f— W�24�d1?i e4&1!'" Title Office Assistant Date 8/1 /216 <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 DATE 8/1/2016 <br />EH230038 (revised 12-11-15) <br />