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SAN - JOAQUIN n Environmental Health Department <br /> - C0UNTY <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 /> D TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/ EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones (209) 461 - 6337 <br /> C Facility Name Abdo Nashir dba National Petroleum Phone # ( 209 ) 235 -6262 <br /> I <br /> L Address 713 EI Dorado Street Stockton , CA 95202 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Malik Phone # ( 510 ) 932-4137 <br /> o ' Contractor Name Elite IV Contractors Phone # (209 ) 461 - 6337 <br /> T Contractor Address 2535 Wigwam Drive Stockton , CA 95205 CA Lic # 1001331 Class A- Hazmat <br /> A Insurer Midwest Employees 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 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S Att hment With Conditions) <br /> A 77 <br /> N Plan Reviewers Name r Date <br /> T <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC TH 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 Signatu Title Administrative Assistant Dale 6/ 10/2021 <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 06/ 10/2021 <br /> 2 of 6 <br />