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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 /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan M 209-461-6337 <br /> A <br /> C Facility Name <br /> Bills 76 Phone# 209-814-3581 <br /> l Address 633 E Victor Rd Lodi Ca 95242 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Ruppi Padda Phone# 209-814-3581 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> O <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 Class A-HAZ <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> T <br /> T ICC Technician's Name Expiration Date <br /> R <br /> ICC 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 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> F, U Approved pproved with conditions _� Disapproved <br /> L �(S Atta hmentWith Conditions) <br /> AN Plan Reviewers Name' " Datea c1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDAN ITH 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 Office Assistant Date a'�� I <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# 209-461-6337 <br /> ADDRESS 2535 Wigwam Or Stockton Ca 952-075�� <br /> SIGNATURE DATE <br /> EH230038(revised 12-11-15) 2 <br />