Laserfiche WebLink
. Environment <br /> � l par VESON HQU ( N <br /> COUNTY <br /> DEC 21. 2021 <br /> APPLICATION FOR UNDERGROUND STORAGI ' I '`aNK <br /> RETROFIT OR PIING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: DEPARTMENT <br /> ❑ TANK RETROFIT CKPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller (209) 461 -6337 <br /> C Facility Name One Stop Phone # (209) 8234081 <br /> 1 Address 1151 Louise Ave Manteca , CA 95336 <br /> L <br /> TCross Street <br /> Y Owner/Operator Hari Kamboj Phone # (209) 823 -4081 <br /> C Contractor Name Elite IV Contractors Phone # <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr CA Lic # 1001331 Class A- HAZ <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> TICC Technician ' s Name Expiration Date <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 112, etc. ) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name yj r Date I Z 103 11 <br /> 20 <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 COMPENSAT,IOMM LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFOR NQE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." rr l r puMtl <br /> Applicant's Signature �//r/ , t L Title Office Manager Date 12/21 /21 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank . If the party designated below is different than the permit applicant, e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Carrie M lerTITLE Office Manager PHONE # (209) 461 -6337 <br /> ADDRESS 253 Wigw m Dr Stockton CA 95205 <br /> SIGNATURE (/ \ /G"U , DATE 12/21 /21 <br /> 2of6 <br />