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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/ RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 209461 -6337 <br /> C Facility Name BAP Enterprises INC/Wilson way Chevron Phone # 209 -942-2344 <br /> I <br /> L Address 473 N . Wilson Way Stockton , CA 95205 <br /> TCross Street <br /> Y Owner/Operator Parl Judge Phone # 209- 942 -2344 <br /> C Contractor Name Elite IV Contractors Phone # 209461 - 6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr . Stockton CA 95205 CA Lic # 1001331 class A- HAZ <br /> A Insurer Midwest Employers Casualty Company Work comp # BNUWC 0133392 <br /> T <br /> T ICC Technician ' s Name Chris Adams 8230218 Expiration Date 4/ 17/2020 <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 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name i4; 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 Service Coordinator Date 6 -27-2019 <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 Olivia Marie Ojeda TITLESevlce COOrinator PHONE # 209-461 -6337 <br /> ADDRESS 2535 Wigwam Dr . Stockton , CA 95205 <br /> SIGNATURE DATE 6 - 27-2019 <br /> EH230038 ( revised 1 2-1 1 - 1 5) 2 <br />