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S (-1 A IV 11'1 ` Il ( 1 1A jl I (ll Fnvironmental Health Department <br /> 'CV 0lUN (NT <br /> T1Y —V- -- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone It Deborah dones (209) 461 "633Z <br /> Facility Name Phone # <br /> Country Ma Gas & Food 209 914- 5583 <br /> � Address 34243 Chrisman Rd Tracy , CA 95304 <br /> Cross Street <br /> of <br /> Y Owner/Operator Sandu SinghPhone # 914m5583 <br /> o Contractor Name Elite IV Contractors Phone # 209 61 -6337 <br /> NContractor Address CA Lic dl Class <br /> T 1001331 A- azmat <br /> R Insurer <br /> A Midwest Employers Casualty Company Work Comp # BNUWCO 33392 <br /> D ICC Technician's Name Expiration Date <br /> T <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i,o. 07 PIP410 Dump, Bt look doleclor, UDC 112, oto.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L -(See attachment With Conditions) <br /> A itN Plan Reviewers Name Date 23 IZC �e, i <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR At46CWTIH N4DAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS 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 /> I <br /> AppIIca nI's SIgnalur6 n v- _ ex1 . . TlueAdministrative Assistant Data 2 /09/2021 <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 Assistant PHONE # (209) 461 -6337 <br /> ADDRESS 2535 Wigwam Drive Stockton CA 95205 , <br /> i <br /> SIGNATURE /)�a( DATE 2/09/2021 <br /> i <br /> 2ofB <br /> i <br /> I <br />