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S A ISI JOAQUIN <br /> OdQUIN Environmental Health Department <br /> - C0UN7Y _ . . . <br /> APPLICATION FOR UNDERGROUND STORAGjk _ ' 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 # Carrie Miller ( 209 ) 461 -6337 <br /> � <br /> Facility Name EI Dorado Food Mart Phone # (209) 943 - 1311 <br /> I Address 2320 N . ElDorado ST Stockton , CA 95204 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Bob & Kathy Lutz Phone # (209 ) 483-7671 <br /> C Contractor Name Elite IV Contractors Phone # (209 ) 461 -6337 <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class A <br /> T <br /> A Insurer Midwest Employers Casualty Company work Comp # BNUWC0133392 <br /> T <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 112, etc. ) Installed <br /> T <br /> A <br /> N <br /> Approved with conditions Ll <br /> P Ll Approved <br /> L (See Attachment With Conditions) <br /> A _ <br /> IN Plan Reviewers Name I _ e C 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 Signature `BGG Title Office Manager Date 7/ 13/2022 <br /> i <br /> BILLING INFORMATION : i <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 Carrie Miller TITLE Office Manager PHONE # 7/ 13/2022 <br /> ADDRESS 2535 Wigwam Dr Stockton , Ca 95205 <br /> DATE 7/ 13/2022 <br /> SIGNATURE <br /> I <br /> 2of6 <br /> I <br />