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SAN JOAQUIN <br /> OAQUIN Environmental Health Department <br /> COUNTY - <br /> - <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 /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT CK UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones / Administrative Assistant <br /> C Facility Name Quik Stop Markets #39 Phone # (925) 2224844 <br /> I Address 2285 E Fremont Street Stockton , CA 95205 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Owner, EG Retail America / Operator, Gurinder Singh Phone # (925) 222-7844 <br /> C Contractor Name Elite IV Contractors Phone # (209) 461 =6337 <br /> 0 <br /> N Contractor Address 2535 Wigwam Drive Stockton , CA 95205 CA Lic # 1001331 Class A- Hazmat <br /> T <br /> R Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> A <br /> c ICC Technician' s Name Expiration Date <br /> T <br /> R ICC Installer's Name Expiration Date <br /> Tanks stem work area Date UST <br /> y Tank Size Chemicals Stored Currently Installed <br /> ii.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L e Attachment With Conditions) <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA 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 /> NTRACTORS <br /> OAT IN THE PERFORMAINCE OF HOE WORK FOR IWHICH OTHIS PERMIT IS IS <br /> ISSUED, II SHALL NG OR OEMPLOY ICERTIFIESNG SIGNATURE I <br /> PERSONS SUBJECT WORKER'S COMPENSATION CERTIFY <br /> THAT ION LAWS <br /> OF CALIFORNIA:' � (J <br /> Applicants Signator-"'"� m � ' � T(8e Administrative Assistant Date 4/27/2021 <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 <br /> Deborah Jones TITLE Administrative Assistant PHONE # (209) 461 -6337 <br /> ADDRESS 2535 Wi wam Drive Stockton , CA 95205 <br /> SIGNATURE- DATE <br /> 4/27/2021 <br /> 2of6 <br /> �I <br />