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S A N - JOAQUIN <br /> OAQ IIN Environmental Health Department <br /> Co UN TY ----. <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFI u 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 # Deborah Jones Administrative Assistant <br /> C Facility Name Quik Stop Markets # 120 Phone # ( 209 ) 478 -7149 <br /> L <br /> Address 9321 Thornton Road Stockton , CA 95209 <br /> I Cross Street <br /> T <br /> Y Owner/OperatorQuil< Stop Markets # 120 Phone # (209 ) 478-7149 <br /> C Contractor Name Elite IV Contractors Phone # (209 ) 461 -6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Drive Stockton , CA 95205 CA Lic # 1001331 c ►assA- Hazmat <br /> A Insurer Midwest Employers Casualty Company work comp # BNUWC0133392 <br /> C <br /> T 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 /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc. ) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S e A chment 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 4/21 /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 Wiqwam Drive Stockton CA 95205 <br /> SIGNATURE ` DATE 4/21 /2021 <br /> I <br /> 2of6 <br />