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C I ELVED <br /> Environ er�l nlaE <br /> SAN JOAQUIN <br /> COUNTY - I OCT 1, 212021 <br /> APPLICATION FOR UNDERGROUND STORAGE �I, I OONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMI VIR <br /> DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT N UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones / (209) 461 -6337 <br /> Facility Name Short Stop Phone # (209) 369- 3697 <br /> I <br /> L Address 20 W Turner Road Lodi , CA 95240 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Sam Hirsch Phone # (209) 369-3697 <br /> 0 <br /> Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <br /> T Contractor Address 2535 Wigwam Drive Stockton CA 9520 CA Lic # 1001331 class XHazmat <br /> A Insurer Midwest Employers Casualty Co . Work comp # BNLIWC0133392 <br /> Q <br /> T ICC Technician's Name Expiration Date <br /> Q ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ElDisapproved <br /> L (Se)Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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 /> Applicant'sSignatUre Title Administrative Assistant Date 10/ 12/2021 <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 Administrative AssistantPHONE # (209) 461 -6337 <br /> ADDRESS 2535 Wigwam Drive Stockton , CA 95205 <br /> SIGNATURE DATE 10/ 12/2021 <br /> 2of6 <br />