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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, Calffomia 95205 DEC 16 2015 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT HEALTH DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Came 209-461-6337 <br /> A <br /> C Facility Name Geor es Mini Mart Phone# 209.727-3064 <br /> � Address 18662 Highway 88 Lockford <br /> TCross Street <br /> Y OWner/Operator Rupi and Bill Phone# 209-914-8735 <br /> C Contractor Name Elite IV Contrcators Phone# 209 61-6337 <br /> T Contractor Address 2535 Wigwam Dr Stockton CA Lic# 1001331 Class A-HAZ <br /> A Insurer Berkleynet Work Comp# NBUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> Ii.e.87 plpkp eemp,91 leek detegot.UDC IM.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approv pproved with conditions ❑ Disapproved <br /> L ( A hdu nt With Conditions) _ <br /> A <br /> N Plan Reviewers Name Data <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.- CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 7 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> ApplicanCe Signature `'"'_-- Title Office Manager Date 12/16/15 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff Ume 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 Elite IV Contrcators-Carrie Miller TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr.-7Stockton CA 95205 <br /> SIGNATURE (� W DATE 12/16/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />