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SAN10 A Q U I N Environmental Health Department <br /> -- COUNTY - - <br /> APPLICATION <br /> OUNTY - - <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209-461 -6337 <br /> A <br /> C Facility Name Emils Liquor Phone # 209499-2693 <br /> 1 Address 1405 California St Escalon Ca 95320 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Chako Thomas Phone # 209499-2693 <br /> c Contractor Name Elite IV Contractors Phone # <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A-HAZ <br /> T <br /> R Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> A <br /> o <br /> r ICC Technician's Name Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 12, etc,) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L e ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDNULATH 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 /> Applicant's Signature 7YI, 711k Title Office Assistant Date <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank . If the party designated 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 # 209-461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE DATE <br /> 2 of 6 <br />