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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 JUN 0 7 2017 <br /> APPLICATION FOR UNDERGROUND STORAGER0NNI! _NTP,L HEALTH <br /> RETROFIT OR PIPING REPAIR PERMI DFP ^TNiFPJT <br /> THIS PERMIT EXPIRES 180 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&Telephone# Megan 209-461-6337 <br /> A <br /> G Facility Name Jahant Food & Fuel jPbone#209-327-2863 <br /> I Address 2432 N Highway 99 Acam o Ca 95220 <br /> 1 Cross Street <br /> T <br /> Y Owner/operator Mr. Singh Phone# 209-327-2863 <br /> O <br /> 0 Contractor Name Elite IV Contractors I Phone# 209-461-6337 <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CALIc# 1001331 class A-HAZ <br /> A Insurer Midwest Employers Casualty Company work Comp# BNUWC0133392 <br /> T ' <br /> ICC Technicians Name <br /> T Expiration Date <br /> ICC Installer's Name <br /> RD Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (Is.87 PIPh9 scary,911eak Eeie .UDC IR,etc) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved t1 Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <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: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OFTHE 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 /> Applicant's Signature Me o It"'(C cea T. Office Assistant Date 6/7/2017 <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 Megan Mitchell TITLE Office Assistant PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE Megas7 MitcheGG DATE 6/7/201 <br /> EH230038(revised 12.11-15) 2 <br />