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SA N JOAQUIN 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 # (209) 461 -6337 <br /> C Facility Name Arch Arco AM PM Phone # (209) 948-2438 <br /> I Address 4855 S . HWY 99 , Stockton CA 95215 <br /> L <br /> TCross Street <br /> Y Owner/OperatorJivtesh Gill Phone # <br /> o Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <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 /> RICC 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 /> K <br /> P ❑ Approved proved with conditions ❑ Disapproved <br /> L (S �4t chment With Conditions) <br /> A _ <br /> N Plan Reviewers Name Date Z, <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENV ONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE 9FTHE 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 COM PE SATION LAWS OF CALIFORN CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERF RMANCE OF THE WORK Fq IC THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA, <br /> Applicant's Signatu e l k4tle Office Manager Date 3/8/2022 <br /> BILLING INFORMATION : <br /> 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 <br /> Carrie Mill Manager TITLE g PHONE # ( )Office Mana 209 461 -6337 <br /> ADDRESS 25 5 Wigwa Dr Stockton , Ca 95205 <br /> SIGNATUREc2tAd� DATE 3/8/2022 <br /> 2of6 <br />