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i <br /> SAN JOAQUIN Environmental He Dea r�t V f_ =" <br /> COUNTY <br /> MAY 0 7 2021 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> PERMIT / SERVICES <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 <br /> � Facility Name Quik Stop Markets # 124 Phone # (209) 823-7628 <br /> L <br /> Address 505 N Main Street Manteca , CA 95336 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Quik Stop Markets , Inc . Phone # (508 ) 270- 1400 Ext 4469 <br /> C Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <br /> 0 <br /> N Contractor Address 2535 Wigwam Drive CA Lic # 1001331 class A- Hazmat <br /> T <br /> A Insurer Midwest Employers 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 12, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name ` \Ax I I� .) 0 Date 0 5113 1 j <br /> 2021 <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 Signaturi Title Administrative Assistant Date 5/07/2021 <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 DriveStockton , CAA 95205 <br /> SIGNATURE DATE 5/07/2021 <br /> 2of6 <br />