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SANJOAQUIN Environmental Health Department <br /> COUNTY <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 REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#l �x>'7zh Jones(;a9) Y61_(,07 <br /> C Facility Name Arco am/pm Phone#(209) 366-1414 <br /> 1 Address 14931 N Flag City Blvd Lodi, CA 95242 <br /> I Cross Street <br /> T <br /> Y Owner/OperatorRupinder Pada Phone#(209) 366-1414 <br /> Q Contractor Name Elite IV Contractors Phone#(209)461-6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Drive Stockton, CA 95205 CA Lic#1001331 Cass A-Hazmat <br /> A Insurer Midwest Employers Casualty Company Work comp#BNUWC0133392 <br /> TICC Technician's Name Expiration Date <br /> RICC 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 FI Approved Approved with conditions Disapproved <br /> L (See 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's Signature/ <br /> " <br /> _ S Title Administrative Assistant Date 3/24/2021 <br /> i <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 /> r _ <br /> SIGNATURE �- '� ` DATE 3/24/2021 <br /> 2of6 <br />