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ENVIRONMENTAL HEALTH DEPARTI ;b;bVE <br /> SAN JOAQUIN COUNTY APR 27 2016 <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 /> D TANK RETROFIT O PIPING REPAIR/RETROFIT D UDC REPAIFURETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 209-461-6337 <br /> A Facility Name Save On Gas& Liquor Phone# 209-239-4700 <br /> I <br /> L Address 420 W.Yosemite Ave. Manteca CA 95337 <br /> 1 Cross Street <br /> Y Owner/Operator Mr.Singh Phone# 510-734-4111 <br /> o Contractor Name Elite IV Contractors Phone# 209.461-6337 <br /> T Contractor Address 2535 Wt warn Dr Stockton CA CA Lic# 1001331 Class A-HAZ <br /> A <br /> Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> Q ICC Technician's Name Expiration Date <br /> T <br /> oICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Dale UST <br /> (i.e.87 pip!W sump.91 leak detector.UDC 112.eta) Installed <br /> T <br /> A <br /> N <br /> K <br /> P I_] Approved Approved with conditions ❑ Disapproved <br /> L y�f (see �ttaacchment With Conditions) <br /> A <br /> N Plan Reviewers Name ,y�j�C oAl/� •'A U bO 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 SHAL_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: "I 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" n <br /> Applicants SlgnaNre C. rine Office Manager oB1e 4/27/16 <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 Carrie M Iller-Elite IV Contractors TITLE Office Manager PHONE#_209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE C4&4Z4 r A4' DATE 4/27/16 <br /> E11230038(revised 07-17-2014) <br /> 2 <br />