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4UO Itn7 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY REp 4 4 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 FEB ) 2 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE T <br /> RETROFIT OR PIPING REPAIR PERMIT�VIRONMENTAV- HEALTH <br /> nFP?QTrf-r_F,.T <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ME an 209-461-6337 <br /> A <br /> C Facility Name Chevron Phone# 209-836-9427 <br /> � Address 3775 N Tracy Boulevard Tracy Ca 95304 <br /> TCross Street <br /> Y Owner/Operator Debbie Phone# 209-836-9427 <br /> C Contractor Name Elite Phone# 209-461-6337 <br /> T Contractor Address CA uc# 1001331 Class <br /> A Insurer M'dwest Employis Casualty an work comp# BNUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> RICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (1.e.aT pong weep.91 leak detemr,UDC IQ,em) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved )Approved With conditions Ll Disapproved <br /> L la'hment With Conditions) <br /> A 21141 <br /> N Plan Reviewers Name 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,1 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 /> Ap fimnfsSlgaatu. / nae OfficeAssistant Date 2/12/2018 <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 OfflrP ACSIStant PHONE# 209-461-6337 <br /> ADDRESS 2535 WigwaannDrr Stockton Ca 95205 <br /> �/ ' we <br /> SIGNATURE � t" DATE 2/12/2018 <br /> EH230038(revised 12-11-15) 2 <br />