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NVI NIDI TAL ALT r W <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 JUN .1 <br /> Telephone : (209 ) 468.3420 Fax : (209 ) 468-3433 <br /> I IO I`�iE111 A HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE ) t M EN T <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT ❑ PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # <br /> Project Contact & Telephone # Megan M 209461 -6337 <br /> A �n 1 Phone # 925-783-6102 <br /> C Facility Name v r vt <br /> 1 25651 N Hwy 99 Acampo Ca 95220 <br /> Address <br /> i L <br />€ I Cross Street <br /> T Phone # 925-783-6102 <br /> Y Owner/Operator Tony Singh <br /> C Contractor Name Elite IV Contractors Phone # 209-461 6337 <br /> oA-HAZ <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class <br /> T <br /> R Work Comp # BNUWC0133392 <br /> A Insurer Midwest Employer Casualty Company <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Date UST <br /> Tank system work Earea Tank Size Chemicals Stored Currently Installed <br /> (i.e. 87 piping sump, 91 leak detecto /2, etc.) <br /> T <br /> A <br /> N <br /> K <br /> P ❑ ApprovedApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A I � s119 <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, 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 /> pplicant's Signature Title Office Assistant Date �C <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expendede and permit payment coverage the party must acknowledge tank. <br /> If <br /> the party designated below is different than the permit applicant, e .g . property <br /> responsibility for the billing by signature and date below. <br /> NAME <br /> Megan Mitchell TITLE Office Assistant PHONE # 209-461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE Y`6DATE <br /> �` <br /> EH230038 (revised 12-11 -15) 2 <br />