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SAN JOAQUIN <br /> O n Q U I N Environmental Health Department <br /> �._ ._ ICY n U N -L. Y I r. <br /> APPLICATION FOR UNDERGROUND STORAGE:. `u 'ANK <br /> RETROFIT OR PIPING REPT PERV34 ' II <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT 0 PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT ❑ COLD START/ EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # )d3or-a t ,Toav, (V(A ) (bi - 031, <br /> C Facility Name JD ServicesPhone # 209 734 - 8993 <br /> 1 Address 9015 W Walnut Grove Road Thornton , CA 95686 <br /> L <br /> TCross Street <br /> Y Owner/OperatorJawinder Singh Phone # (209) 734 -8993 <br /> C Contractor Name Elite IV Contractors Phone # ( 209) 461 -6337 <br /> O <br /> T Contractor Address 2535 Wigwam Drive Stockton , CA 95205 CA Lic # 1001331 Class A- Hazmat <br /> R Insurer Midwest Employers Casualty Company work comp # BNUWC0133392 <br /> T <br /> T ICC Technician' s Name Expiration Date <br /> Q <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 surnp, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> I <br /> I <br /> P ❑ Approved Z Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A ` i <br /> N Plan Reviewers Name DC7 kn , 64g\ r2 - Date 5 / (A4o^A <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 Signat4e;�=+���"S� &k t �'! L Y Title Administrative Assistant Date 4/22/2021 <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 TITLEAdministrative Assistant PHONE # ( 209 ) 461 -6337 <br /> ADDRESS 2535 Wigwam Drive Stockton CA 95205 <br /> SIGNATURE �' DATE 4/22/2021 <br /> 2of6 <br />