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SANJaAQ U I N Environmental Health Department <br /> � <br /> - COUNTY <br /> APPLICATION FOR R PSP NK <br /> RETROFIT NG REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW, <br /> 0 TANK RETROFIT D PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT D COLD M S ARTIEGRADE <br /> 209-46 <br /> F EPA Site # Project Contact & Telephone # <br /> Phone # 209-461 -6337 <br /> A Facility Name Save on Fuel <br /> C <br /> I Address 420 W Yosemite Ave Manteca Ca 95337 <br /> L <br /> I Cross Street Phone # 209-239-4700 <br /> T <br /> Y Owner/Operator Vikash phone # 209-461 -6337 <br /> c Contractor Name Elite IV Contractors <br /> 0 CA LiC # 1001331 Class A-HAZ <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 BNUWC0133392 <br /> T <br /> Work Comp # <br /> A Insurer Midwest Employers Casualty Company Expiration Date <br /> C ICC Technician' s Name <br /> T Expiration Date <br /> O <br /> R ICC Installer' s Name Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (Le. 87 piping sump. 91 teak detector, UDC 112, etc.) <br /> T <br /> A <br /> N <br /> K <br /> ❑ Approved Approved with conditions <br /> ❑ Disapproved <br /> P (See Attachment With Conditions) <br /> A Date S I11 <br /> N Plan Reviewers Name <br /> ANANCES , STATE <br /> a AND RULES AND REGULATIONS OF SAN <br /> UNTY ORt <br /> "I CERTIFY <br /> AT IN <br /> APPLICANT MUST PERFORM ALTH DIN OR NCE RTMENTTOWNER ORH SAN OUIN LICENSOED AGENT'S <br /> wP oY ANY PERSONSIGNATURE IN N SUCH H A MANNERES THE OAS TO BECOME SUBJECT TO <br /> JOAQUIN COUNTY , ENVIRONMENTAL <br /> THE PERFORMANCE OF THE WORK FOR THIS PERMIT IS ISSUED, I SHALL NOTURE <br /> WORKER'S COMPENSATION A THE WORK OR CALIFORNIA, CHONTR THIS PERMIT IS ISS ED,NG ,II SUBCONTRACTING <br /> SUBJEC CERTIFIES <br /> WORKER'S OC COMPENSATION LAWS <br /> THAT IN THE kall <br /> OF CALIFORNIA:' Date (� <br /> Titre Office Assistant . <br /> Applicant's Signature <br /> BILLING INFORMATION : <br /> Indethe earbto be il tendbeyond laent o <br /> verage per <br /> tank, If theptydesgnatd belowis different than the <br /> pemitapplicant, <br /> e .g . popertyownerthe party must <br /> acknowledge this responsibility for the billing by signature and date below. 209-461 -6337 <br /> NAME Megan Mitchell <br /> TITLE Office assistant PHONE # <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> DATE <br /> SIGNATURE <br /> 2 of 6 <br />