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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 OCT 3 0 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TAN NVIRONMEN L HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEIN/ MENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR U RADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name Quik Stop 138 Phone# 800-972-0982 <br /> � <br /> Address 1153 Lincoln Blvd Tracy Ca 95376 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Quik Stop Markets Inc Phone#' 800-972-0982 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> T Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casualty Company work comp# BNUWC0133392 <br /> C <br /> T ICC Technician's Name Expiration Date <br /> Q ICC Installer's Name Expiration Date <br /> R <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 (S Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE TH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTME T.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PE IT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHI H THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Office. Asgistint Date 10/27/2017 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be tilled for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is d ferent 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 Megan Mitchell TITLE Office Assistant PHONE# 209-461-6337 <br /> ADDRESS 2535 Wig /am Dr Stockton/Ca//95205 <br /> SIGNATURE Meaair MI heU DATE 10/27/2017 <br /> EH230038(revised 12-11-15) 2 <br />