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ENVIRONMENTAL HEALTH DEPARTMENT t <br /> SAN JOAQUIN COUNTY rt aECEIVE f <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : ( 209 ) 468 -3420 Fax : (209 ) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK 1��R�#;'��_EN7AL HEAL7N <br /> RETROFIT OR PIPING REPAIR PERMIT 't1' Jcs <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 # Megan M 209461 -6337 j <br /> A Georges Mini Mart Phone # 209-814-0300 <br /> C Facility Name g <br /> Address 18662 N Hwy 88 Lockeford Ca 95257 <br /> L I <br /> T <br /> Cross Street <br /> Y Owner/Operator Ruppi / Brikram Phone # 209-814-0300 <br /> C Contractor Name Elite IV Contractors Phone # 209-461 -6337 <br /> O <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 Company Work Comp # BNUWC0133392 <br /> c <br /> T ICC Technician's Name Expiration Date <br /> D <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P El Approved Approved with conditions ❑ Disapproved <br /> L (See ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name I ' �(.x.i/ �. �n� Date J `tE At <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," 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 /> Ll <br /> /� <br /> Applicant's Signature <br /> Title Office Assistant Date Z,)Z <br /> _ / <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 Assistant PHONE # 209461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE / DATE <br /> EH230038 (revised 12- 11 -15) 2 <br />