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S n N 1 JOAQUIN <br /> 0 n Q I + I N Environmental Health Department <br /> --F—iC�I O U 1NiTl�Y - - - <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 A PIPING REPAIR/RETROFIT A UDC REPAIR/RETROFIT A COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones (209) 641 -6337 <br /> C Facility Name Ranhawa Petroleum dba EI Dorado Gas & Food Mart Phone # (209) 451 -4632 <br /> I Address 1901 S EI Dorado St <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Avinash Singh Phone # ( 510) 557"4508 <br /> C Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <br /> O <br /> N Contractor Address 2535 Wigwam Drive CA Lic # 1001331 Class A-Haz <br /> T <br /> R <br /> A Insurer: Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> C <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, uoc 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P J Approved Approved with conditions A Disapproved <br /> L (See Attachmentith Co c�itid s / <br /> A _ <br /> N <br /> Plan Reviewers Name DateO � � <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 THE <br /> 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 THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF <br /> CALIFORNIA:' <br /> Applicant's Signature �Z Title Office Assistant Date 12/01 /2020 <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 Deborah Jones TITLE Office Assistant PHONE # (209) 461 -6337 <br /> ADDRESS 2535 Wigwam Drive Stockton CA 95205 <br /> SIGNATURE DATE 12/01 /2020 <br /> 2of6 <br />