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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY ' <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 JUN 10 2016 <br />APPLICATION FOR UNDERGROUND STORAGE TANK ''"""•���� " <br />RETROFIT OR PIPING REPAIR PERMIT �" , � <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Carrie Miller 209 461-6337 <br />A <br />C <br />Facility Name Quik Stop #125 Phone # 209-599-4261 <br />1 <br />L <br />Address 1580 W. Main St, Ripon CA 95366 <br />TCross <br />Street <br />Y <br />Owner/Operator Quik Stop Markets <br />Phone # 800-972-0982 <br />C <br />0 <br />Contractor Name Elite IV Contractors <br />Phone # 209-461-6337 <br />T <br />Contractor Address 2535 Wigwam Dr Stockton <br />CA Lic # 1001331 Class A-HAZ <br />A <br />Insurer Midwest Employers Casulty Company <br />Work Comp #BNUWC0133392 <br />T <br />ICC Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(Le. 87 piping Burn p, 91 leak detector, UDC 112. etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Approved with conditionsDisapproved <br />L <br />(S iiiilettachment With Conditions) <br />A <br />N <br />��....�� � <br />Plan Reviewers Name /A Date L <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 AGENTS 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 PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature_ Title Office Manager Date 6110/16 <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 />Elite IV Contrcators - Carrie Miller TITLE Office Manager PHONE # 209-461-6337 <br />ADDRESS 2535 Wigwam Dr �j�Stockton CA 95205 <br />SIGNATURE rAk&41' DATE 6/10/16 <br />EH230038 (revised 07-17-2014) <br />2 <br />