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i <br /> S A N . � A OU <br /> IN <br /> Environmental Health Department <br /> �� C 0 U N TY� .. <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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 2094616337 <br /> � <br /> Facility Name Chevron Phone # �(j — jL� - ; ! <br /> I Address <br /> L 437 N Wilson Way Stockton Ga 95205 <br /> I Cross Street I <br /> T I i <br /> Y Owner/Operator Phone # 61 er ` `YQ9�� 0`1 <br /> o Contractor Name Elite IV Contractors Phone # <br /> T Contractor Address2535 CA Lic #gwam Dr Stockton Ga qsqns1001331 Class Z <br /> A Insurer Midwest Employers CasualtyCompanywork comp # g <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 /> (Le, 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 ❑ Disapproved <br /> L ee A achment With Conditions) <br /> N Plan Reviewers Name Date 5 ,�® <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA TH 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." j <br /> Applicant's Signature Title Offlice AssdstantDaie I �� <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 Megan Mitchell TITLE Office Assistant PHONE # 209461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton QJa95205 <br /> SIGNATURE /i�%�C�'� DATE <br /> 2of6 <br /> w <br />