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VEEnvironmental F'F Doul D <br /> SAW, 1 � AQUIN <br /> . c0U NT JUL 0 8 2020 <br /> APPLICATION FOR UNDERGROUND STORAGE TA t I� VIRHEALTHONMENTAL AL H <br /> RETROFIT OR PIPING REPAIR PERMIT ONME T H <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 209461 -6337 Megan Mitchell <br /> A <br /> C Facility Name Estes Express Lines Phone # 209-982-1841 <br /> I <br /> L Address 7611 S Airport Way Stockton Ca 95206 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Robert Mary Phone # 209-982-1841 <br /> C Contractor Name Elite IV Contractors Phone # 209-461 -6337 <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A-HAZ <br /> T <br /> R <br /> A Insurer Midwest Employer Casualty Comapny Work Comp # BNUWC0133392 <br /> C <br /> T ICC Technician's Name Expiration Date <br /> 0 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 plping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved LJ Approved with conditions ❑ Disapproved <br /> L o 1 (See Attachment With Conditions) <br /> N Plan Reviewers Name i Gtw� ► V Sl� Date of I ) 3 1 J <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 <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." GDNT CT HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA CE OF THE WORK FOR WHICH THIS ERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION (AWS <br /> OF CALIFORNIA." n <br /> Applicant's Signatu ' l Title Office Assistant Date /J 20 <br /> BILLING INFORMATION : <br /> Indicate the response a party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank . If the partVd signated 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 Megan Mitchell <br /> SIGNATURE l/ / DATE 7/3/2020 <br /> 2 . of 6 <br />