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ENVIRONMENTAL HEALTH DE A <br /> P RM, TFY-- D <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 D EC 0 6 2017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TA VII IAE I i-, HEALTH <br /> RETROFIT OR PIPINGPAI IT r,F P YN g' MIIE-1 l <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 209-461-6337 <br /> � Facility Name Stop N Shop Phone# 209-250-6877 <br /> 1 Address 1856 Country Club Blvd Stockton <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Jagraj Brar Phone# 209-250-6877 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> O <br /> N Contractor Address 2535 Wigwam Dr CA Lic# 1001331 Glass A-HAZ <br /> T <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> C <br /> T ICC Technician's Name Michal Kennard ICC EXP 10/28/2018 Expiration Date WC Exp10/01/2018 <br /> o <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 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved tc <br /> proved with conditions ElDisapproved <br /> L 1---(§e>i hment With Conditions) <br /> A I, <br /> N Plan Reviewers Name Date i <br /> APPLICANT MUST PERFORM ALL WORK IN ACC CE 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 COMPENS N LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFO MA CE 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 Signatur Title 8 Date <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 I ontractors /Carrie Miller TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 535 Wigwam Dr Stockton CA 95205 f // <br /> SIGNATURE G DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />