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S (l/ � N JOAQUIN <br /> O A Q I I I N Environmental Health Department <br /> CI) 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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones / (209) 461 -6337 <br /> � Facility Name Interstate A Enterprises , Inc / City Food & Liquor Phone # (209) 6474273 <br /> I Address 16470 Cambridge Drive Lathrop , CA 95330 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Amarjit Khinda Phone #- (209 ) 647-4273 <br /> C Contractor Name Elite IV Contractor Phone # (209) 461 -6337 <br /> 0 <br /> N Contractor Address 2535 Wigwam Drive CA Lic # 1001331 Class A-Hazmat <br /> T <br /> A Insurer Midwest Employers Casualty Co . work comp # BNUWC0133392 <br /> C <br /> T ICC Technician 's Name Expiration Date <br /> oICC Installer' <br /> R s Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> i <br /> [FP Approved Approved with conditions ❑ Disapproved <br /> (S a Attachment With Conditions) <br /> Plan Reviewers Name v Date R L07 <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's Signature �tYcC � ��r "L- �� Title Administrative Assistant Date 10/20/2021 <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 /> SIGNATURE DATE 10/20/2021 <br /> 2of6 <br />