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0 0 <br /> ENVIRONMENTAL HEALTH DEPAI T� <br /> SAN JOAQUIN COUNTY VVCC <br /> 1868 E. Hazelton Ave., Stockton, California 95205 APR 0 2 1015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TA4:NVIRONMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT FALTHOEPAR7rNT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br /> O TANK RETROFIT O PIPING REPAIRIRETROFIT O UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Kim 209-461-6337 <br /> � Facility Name Arch Arco AM PM <br /> 1 Phone# 209-948-2438 <br /> L Address 4855. HWY 99 Frontage Rd. <br /> TCross Street <br /> Y Owner/Operator Jivtesh Gill Phone# 948-2438 <br /> c contractor Name Elite IV Contractors Phone# 461-6337 <br /> RContractor Address 2535 Wi warn Dr. CALX#66076 Class ABC10HAZ <br /> A Insurer Markel wo k comp# <br /> T ICC Technician's Name MWC0070230 <br /> R Expiration Date <br /> ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Date UST <br /> (1.e,e7 plphq..g 91 b mtepor,UDC 12,ek.) Chemicals Stored Currently <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved proved with Conditions ❑ Disapproved <br /> A (S achment With Conditions) <br /> N Plan Reviewers Name // <br /> Date T <br /> P <br /> JOAQUIN COUNTY,NT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT5 SIGNATURE CERTIFIES THE FOLLOWING: '1 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 /> RKER'S PERFOPENSATIO WS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMA E F THE WORK FOR WHICH THI MIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' I <br /> Appffmnrs Smnatura - 46I Office Manager <br /> Date 4/1/2015 <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 billin by si nature and date below. <br /> NAME Came Miller- lite IV Contractors Office Manager TITLE g PHONE/ 209-461-6337 <br /> ADDRESS 2535 Wi wa D - <br /> SIGNATURE - "U DATE <br /> EH230038(revised 07.17-2014) <br /> 2 <br />