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SANI (1 n Q U I N Environmental Health Department <br /> _.._. C O U lNiTljY# . 1! <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <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 # Megan Mitchell 909.461 - <br /> C 6337 <br /> Facility Name Western Food and Fuel Phone # 209-346 -9232 <br /> I <br /> L Address 3032 Waterloo Rd Stockton Ca 95205 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Jay Ardass Phone # 209-346 -9232 <br /> c Contractor Name Elite IV Contractors Phone # 209461 -6337 <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 001331 Class _ H Z <br /> A Insurer Midwest EmployersCasualty Companywork comp # BNUWC0133392 <br /> C <br /> T ICC Technician's Name Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 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 chment With Conditions) <br /> A - 0//,:7,/Z,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 OF THE WORK FOR WHICH TH PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFOR CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I -CERTIFY_ <br /> THAT IN THE PERFORMANCE qFj WORK FO WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signalure I/ Title Date <br /> L/ BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e. g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Mpgan MitrhAll TITLE nffirA ASRiStnnt PHONE # 209.461 - 6337 <br /> ADDRESS <br /> SIGNATURE �- DATE <br /> 2of6 <br />