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JDA <br /> (tJ�1 ( N Env t tri nfiaf Healfh D6P4t nt w . <br /> .� . COUNTY . ._ w. <br /> f <br /> L _ ; . �jD <br /> i- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERM, s Ike ', r . 4 <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209461 -6337 <br /> C Facility Name Flag City Shell Phone # 209-914-8735 <br /> I Address 6437 Banner St Lodi Ca 95242 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Rupi Padda Phone # 209-914-8735 <br /> o Contractor Name Elite IV Contractors Phone # 209461 -6337 <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 <br /> T CA Lic # 1001331 Class A-HAZ <br /> R Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> A <br /> C <br /> T ICC Technician 's Name Expiration Date <br /> Q <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 1/29 eta) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A i <br /> N Plan Reviewers Name v � 0 Date (D I l � � <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." I I /)'fl <br /> Applicant's Signature M.Title Office Assistant Date � V <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME <br /> Megan Mitchell TITLE Office Assistant PHONE # 209461 .6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE GC�Li DATE <br /> 2of6 <br /> i <br />