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FILE COPY <br /> ENVIRONMENTAL HEALTH DEPART - - <br /> SAN JOAQUIN COUNTY ����� <br /> 1868 E. Hazelton Ave., Stockton, California 95205 SEP 3 0 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK NVIRONMENTA[ <br /> tJCQtTU nCOAC?TAACI,IT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 461-6337 <br /> A <br /> c Facility Name Food Mart Phone# 209 547-1700 <br /> 1 Address <br /> L 2185 W. Fremont St. Stockton, CA <br /> I Cross Street <br /> T <br /> Y Owner/Operator Mr. Joe Jinger Lou Phone# 775-421-9978 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr. CA Lic# 1001331 Class A-HAZ <br /> R <br /> A Insurer Markel Work Comp# MWC0070230 <br /> T ICC Technician's Name Expiration Date <br /> T <br /> 0 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved LfL Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N <br /> A Plan Reviewers Name � j/W"� Date � 'S <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 Tilde Office Manager Date 9/30/15 <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 TITLE Office Manger PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton CA <br /> SIGNATURE DATE 9/30/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />