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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 STORAGE TANK .-AMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan 209-461-6337 <br /> C Facility Name Jahant Food & Fuel Pnone#209-327-2863 <br /> L <br /> Address 2432 N Highway 99 Acam o Ca 95220 <br /> I Cross Street <br /> T <br /> Owner/Operator Mr. Singh Phone# 209-327-2863 <br /> o contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CALic# 1001331 Class A-HAZ <br /> T <br /> R Insurer Midwest Employers Casualty Company work comp# BNUWC0133392 <br /> A <br /> D ICC Technician's Name Expiration Date <br /> T <br /> DICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le.87 piping scary.91 leak Uetecia,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Pian Reviewers Name Dater_ <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 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." 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 an MrtcheGG Tiaa Office Assistant Data 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 Or Stockton Ca 95205 <br /> SIGNATURE Megan AlWheU DATE 6/7/2017 <br /> EH230038(revised 12-11-15) 2 <br />