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• o " <br />THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Megan Mitchell <br />C <br />Facility Name Harry's One Stop Market Phone # 209-461-6337 <br />1 <br />Address 1151 W Louise Ave Manteca Ca 95336 <br />L <br />TCross <br />Street <br />Y <br />Owner/Operator Harry <br />Phone # 209-823-4081 <br />C <br />Contractor Name Elite IV Contractors <br />Phone # 209-461-6337 <br />0 <br />N <br />Contractor Address 2535 Wigwam Dr Stockton Ca 95205 <br />CA Lic # 1001331 Class A-HAZ <br />T <br />R <br />Insurer Midwest Employers Casualty Company <br />Work Comp # BNUWC0133392 <br />A <br />T <br />T <br />ICC Technician's Name <br />Expiration Date <br />0 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />91 leak detacter, UDC 112, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />ri.e. 87 piping sump, etc.) <br />Piping Sump <br />Existing <br />Diesel <br />Unknown <br />T <br />A <br />N <br />K <br />P <br />❑ Approved -Approved with conditions ❑ Disapproved <br />A <br />ee Attachment With Conditions} <br />� <br />N <br />Plan Reviewers Name Date ;t, <br />APPLICANT MUST PERFORM ALL WORKACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL H TH 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: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PE No IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />ri' z Office Assistant <br />Applicant's Slgrlature `� ` 4T)tle 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 Megan Mitchell TITLE Office Assistatnt PHONE # 209-461-6337 <br />2535 Wigwam Dr Stockton Ca 95205 <br />SIGNA <br />EH230038 (revised 112A445) 2 <br />TE /c /V <br />