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R'ug 20 15 09:24a Elite Iv Contractors Inc 2094616342 P.1 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY - <br />1868 E. Hazelton Ave., Stockton, California 95205 RE t l V L <br />Telephone: (209) 468_-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK AUG 2 0 201 <br />RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL. <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW:141=81 Tu r)CD(10TR#C:f IT <br />0 TANK RETROFIT C PIPING REPAIRIRETROFIT O UDC REPAIR/RETROFIT O COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # Kim 461-6337 <br />A <br />c <br />Facility Name 24 GAS & MART Phone # 209 <br />I <br />L <br />Address 1901 S. Eldorado St Stockton <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />Contractor Name Elite IV Contractors <br />Phone # 209.461-6337 <br />N <br />Contractor Address 2535 Wigwam Dr. CA Lic# 660076 Class ABC10 HAZ <br />A <br />Insurer Markel Work Comp# MWC0070230 <br />T <br />ICC Technician's Name Expiration Date <br />R <br />ICC Installer's Name Expiration Date <br />Tank system work area <br />Tank Size Chemicals Stored Currently Date UST <br />e. <br />(. 87 piping sump, 91 Peak delector, UDC 112, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions Disapproved <br />L <br />A <br />e ttachment With Conditions) <br />N <br />Plan Reviewers Nam Date Z� <br />APPLICANT MUST PERFORM ALL WORK IN ACCO NCE 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. 7 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FORY,*iICHHIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />F CALIFORNIA." <br />Applicant's Signature . !'. ! : j ' : i;' Tine Office Manager Dela 8113/15 <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 />Dr. <br />SIGNATUR <br />EH230038 (revised 07-17-2014) <br />2 <br />8/13/15 <br />