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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 <br /> 1868 F. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 NOV 18 2015 <br /> APPLICATION FOR UNDERGROUND STORAGE TANKwIR��� �r�I <br /> RETROFIT OR PIPING REPAIR PERMIT HF=AI TLJ MCRA A.-.-- <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT O PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 209461-6337 <br /> A <br /> C Facility Name Arco AM PM Phone# 209-599-7600 <br /> 1 Address <br /> L 1340 Colony Rd. Ripon CA <br /> Cross Street <br /> T <br /> Y Owner/Operator Ran'eet Singh Phone# 209-5794014 <br /> G Contractor Name Elite IV Contractors Phone# <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr. Stockton CA 95205 CA Lic# 1001331 Class A-HAZ <br /> A Insurer Barkleynet Work Comp# NBUWC0133392 <br /> D ICC Technician's Name Expiration Date <br /> T _ <br /> DICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (ie.87 piping sump,91 leak detector,UDC Ia.era) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions ❑ Disapproved <br /> L (See A tachment With Conditions) <br /> A (� �1 2 <br /> N Plan Reviewers Name�Q I l�l. 0.51 P Date_—ja 'J_= <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 AGENTS 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 /> O <br /> Applkant's Signature t �' rna Office Manager Dam 11/16115 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage par 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 Carrie Miller/Elite IV Contractors TITLE Office Manager PHONE# 209.461-6337 <br /> ADDRESS /72535 Wig'wla�m�Dr. Stockton CA 95205 <br /> SIGNATURE ( 4�itLQ- //C—Ae DATE 11/16115 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />