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i <br /> ENVIRONMENTAL HEALTH DEPARTIl <br /> SAN JOAQUIN COUNTY APR 29 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 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# Carrie Miller 209.461-6337 <br /> C Facility Name Fast& Easy Mart-Chevron Morada Phone# 209-931-6154 <br /> I <br /> L Address <br /> TCross Street <br /> Y Owner/Operator Bill Phone# <br /> C Contractor Name Elite IV Contractors Phone# 209.461-6337 <br /> C <br /> T Contractor Address 2535 Wigwam Dr. Stockton CA CA Lie# 1001331- Class A-HAZ <br /> R Insurer Midwest Employers Casualty Work Comp# BNUWC0133392 <br /> TQ 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 /> 0.9.87p1*9wmp.91leakcl s .UDC/n,W) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved 1 PApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) ' T <br /> A `�aLt1ab r'� .+ AR9:h moi? <br /> N Plan Reviewers Name Date � <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: '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 /> 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.' �/�'���� <br /> Applicants Signature 7 Tl6a Office Manager Date 4/26/16 <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 Elite IV Contractors-Carrie Miller TITLE Office Manager PHONE#209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton CA 95205 <br /> �W4& <br /> SIGNATURE C? 41 DATE 4/28/16 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />