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I <br /> ENVIRONMENTAL HEALTH DEPA <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 I t6 - di9 <br /> Telephone : (209 ) 468- 3420 Fax : ( 209 ) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANRNVIRONVENT AL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <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 # Megan M 209-461 -6337 <br /> Facility Name I- Phone # 466-8969 Steve <br /> L <br /> Address 1126 E Pine Street Lodi Ca 95241 <br /> TCross Street <br /> Y Owner/Operator Steve Kludt Phone # 209-466-8969 <br /> C Contractor Name Elite IV Contractors Phone # 209-461 -6342 <br /> O <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lie # 1001331 Class A-HAZ <br /> R Insurer Midwest Employer Casualty Company Work Comp # BNUWC0133392 <br /> A <br /> T <br /> T ICC Technician 's Name Expiration Date <br /> Q <br /> R ICC Installers 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 1/1, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> li <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR NJITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPAR . 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 Office Assistant Date l/ <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 Office Assistant PHONE # 209461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE "iC^` DATE <br /> EH230038 (revised 12-11 - 15) 2 <br />