Laserfiche WebLink
i <br /> C J�f-i N J 0 A Q U I N Environmental Health Department <br /> C O U N `fh�Y - I V <br /> i 14-11 . 1G 1 T ION rOR UNDERGROUND STORAGE TANK <br /> P ,, T poo T OR PIPING REPAI ? 6-' ER VIIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW. <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # ( 209 ) 461 - 6337 Carrie Miller <br /> C Facility Name Country Club Mobil Circle K Phone # ( 209 ) 838 -5400 <br /> I Address 2575 Country Club Blvd , Stockton CA 95204 <br /> TCross Street <br /> Y Owner/Operator Nick Singh Phone # ( 209 ) 838-5400 <br /> G Contractor Name Elite IV Contractors Phone # (209 ) 461 -6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class A , HAZ <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> C <br /> T ICC Technician ' s Name Expiration Date <br /> 0 <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, otc. ) Installed <br /> T <br /> A <br /> N <br /> I< <br /> P ❑ Approve Approved with conditions ❑ Disapproved <br /> L ( ee At ac ept With Conditions) <br /> 3L23 2NPlan Reviewers Name Date_ 2U Z <br /> APPLICANT MUST PERF91I WORK N CORDA TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, EydIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANC F THE WWORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMP SATION WS OF CALIFO NIA ." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PER OF M 3 OF THE WORK d WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signatu r Title Office Manager Date 3/4/2022 <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 /> Carrie Miller TITLE g er PHONE # ( )Office Manager 209 461 - 6337 <br /> ADDRESS 2535 Wi wam D Stockton , Ca 95205 <br /> SIGNATURE bri DATE 3/4/2022 <br /> I <br /> 2of6 <br /> I <br /> i <br />