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SA N J O A QU I N 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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones / (209) 461 -6337 <br /> C Facility Name Quik Stop Markets # 125 Phone # (209) 5994261 <br /> � Address 1580 W Main Street Ripon CA 95366 <br /> T Cross Street Jacktone Drive <br /> Y Owner Operato Sangram/Satbir Gill Phone # (209) 5994261 <br /> c Contractor Name Elite IV Contractors Phone # (209) 461 =6337 <br /> O <br /> N Contractor Address 2535 Wigwam Drive Stockton , CA 95205 CA Lic # 1001331 Class A-Hazmat <br /> A Insurer Midwest Employers Casualty Company work Comp # BNUWC0133392 <br /> C <br /> r ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Xpproved with conditions ❑ Disapproved <br /> L ( e achment With Conditions) <br /> A J _ / <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 Signatures" ' Title Administrative Assistant Date <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, 41,W fru! a./ DATENr <br /> 2of6 <br />