Laserfiche WebLink
ENVIRONMENTAL T <br /> AN JOAQUIN UNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : ( 209 ) 468-3420 Fax , (209 ) 468-3433 <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 /> J TANK RETROFIT A PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT A COLD START/EVR <br /> UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones (209) 461 -6337 <br /> A <br /> C Facility Name EI Dorado Gas & Mart Phone # (209) 939- 1906 <br /> 1 Address 1605 S EI Dorado St Stockton CA 95205 <br /> L <br /> TCross Street <br /> Y Owner/Operator Aziz Sher Phone # (209) 939- 1906 <br /> C Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <br /> 0 <br /> N <br /> T Contractor Address 2535 Wigwam Drive Stockton CA 95205 CA Lic # 1001331 Class XHAZ <br /> A Insurer Midwest Employer Casualty Company Work Comp # BNUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> R ICC 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 1/2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions A Disapproved <br /> L (See Attachment With Conditi s) <br /> A <br /> N Plan Reviewers Name G Date 4z. <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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA:' /� <br /> Applicant's Signature 4e t�"a'tX Title Office Assistant Date 11 /24/2020 <br /> BILLING INFORMATION ; <br /> Indicate the responsible pa y 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 Deborah Jones TITLE Office Assistant PHONE # (209 ) 461 -6337 <br /> ADDRESS 2535 Wigwam Drive Stockton CA 95205 <br /> SIGNATURE DATE 11 /24/2020 <br /> EH230038 (revised 12AI1 15) 0 2 <br />