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Envir nr . Intal € ealth Depa, rtment ,a <br /> SAN < 10AQUIN <br /> COUNTY -. .. .__. _ it <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> APR L4 2020 ,�,b <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> ,�( 1MENTAL HEALTH i <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMI <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARf1EVI� 'UR�AL E I <br /> i <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209-461 -6337 <br /> APhone # 209 765-2619 <br /> C Facility Name Manteca Liquor Food and Gas <br /> L <br /> Address 890 N Main St Manteca Ca 95336 <br /> Cross Street <br /> T <br /> Y Owner/Operator Jeet Phone # 209-765-2619 <br /> i <br /> Contractor Name Elite IV Contractors Phone # 209-461 -6337 <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A-HAZ <br /> T <br /> 0R Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> FA i <br /> 0 ICC Technician's Name Expiration Date <br /> T i <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 112, etc,) Installed <br /> T <br /> A <br /> N <br /> K <br /> i <br /> FNp ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A 1 i5 � � Ic� a �6 <br /> Plan Reviewers Name a'^' , � SQ Date ll C.0 <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 j <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 <br /> /THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA:' <br /> Office Assistant 4/21 /2020 <br /> Applicant's Signature Title Date <br /> i <br /> BILLING INFORMATION : j <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> i <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 Megan Mitchell TITLE Office Assistant PHONE # 209461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURES DATE 4/21 /2020 <br /> 2of6 <br />