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CEIVED <br /> Enviro me fa Health De Hent <br /> SAN JOAQUIN n n partt. <br /> - COUNTY SEP% 28 2021 <br /> 11 . <br /> APPLICATION FOR UNDERGROUND STORAGE TEWIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <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 /> A Facility Name Orlando 's Market Phone # (209 ) 887- 1100 <br /> I <br /> L Address 18754 State Route 26 Linden , CA 95236 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Sam Orlando Phone # (916) 708-4999 <br /> o Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <br /> T Contractor Address 2535 Wigwam Drive Stockton , CA 95205 CA Lie # 1001331 Class A- Hazmat <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> C <br /> T 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, 67 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 ee A chment With Conditions) <br /> A <br /> N Plan Reviewers Name —' Date. <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCIA H 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: 1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 /> pplicant's Si tare TIBe Administrative Assistant Date 9/28/2021 <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 9/28/2021 <br /> i <br /> I <br /> I <br /> 2of6 <br /> ij <br />