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IN= <br />Environmental Health Department <br />P 311ACQ 0 ISA M hCAE� UliIDERt3R©UND STORAGE 0f1N&� <br />RETROF u UR "1V14`\9�>> REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT 17 PIPING REPAIR/RETROFIT N UDC REPAIR/RETROFIT 0 COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Deborah Jones (209) 461-6337 <br />A <br />C <br />Facility Namehone <br />y CaliforniaCalifornia-Stop � <br /># 209 406-1484 <br />( ) <br />Address 2224 Manthey Road Stockton, <br />CA 95206 <br />L_ <br />I <br />Cross Street <br />T <br />Y <br />Owner/OperatorThien Phan <br />Phone # (209) 406-1484 <br />C <br />Contractor Name Elite IV Contractors <br />Phone # (209) 461-6337 <br />0 <br />N <br />Contractor Address 2535 Wigwam Drive <br />CA Lic # 1001331 Class A-Hazmat <br />T <br />R <br />Insurer Midwest Employers Casualty Company <br />Work comp # BNUWC0133392 <br />ICC Technician's Name <br />Expiration Date <br />T <br />T <br />o <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />12,000 Gallons <br />87 Regular <br />T <br />A <br />12,000 Gallons <br />91 Premium <br />N <br />K <br />12,000 Gallons <br />Diesel <br />P <br />L1 Approved <br />Approved with conditions L1 Disapproved <br />L <br />( e Attrhment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />,I <br />Date O q ( 9 <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, <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />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 <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." C_ <br />Lv,=P,)-M) <br />Assistant 3/23/2021 <br />AppIic <br />ant's Sign at.? <br />Title Administrative Date <br />�1 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 />SIGNA <br />2of6 <br />TEk209) 461-6337 <br />