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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 MAY 05 2016 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK .. r,•�,, r�,�� <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> E <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 209 461-6337 <br /> A <br /> C Facility Name Arco Am/Pm Phone# (209)836-3327 <br /> iAddress <br /> L 550 West Val ico Rd Tracy CA 95376 <br /> TCross Street <br /> Y Owner/Operator Edger Rizkalla Phone# 925)548-7910 <br /> G Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr. GA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Work Comp# BNUWC0133392 <br /> G <br /> T ICC Technician's Name Expiration Date <br /> RICC 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 Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date oZ 0 16 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN G TY ORDINANCES,STATE LAWS, D 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 ( Title Office Manager Date 5/5/16 <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 Cotractors-Carrie Miller TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 25335 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE 70M DATE 5/5/16 <br /> EH230038(revised 07-17.2014) <br /> 2 <br />