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SHAWNEnvironmental Health Department <br /> - COU NTY - - <br /> APIPLICATION FOR UNDERGROUND STORAGE TANK <br /> R,-F. Tq ® FIT OR P PING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller ( 209) 461 -6337 <br /> C Facility Name Flame Liquors Phone # (209 ) 334-3233 <br /> I Address 1301 W. Kettleman Lane Lodi , CA 95240 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Rupi Padda / Shawn Padda Phone # (209) 712-7359 <br /> o Contractor Name Elite IV Contractors Phone # (209 ) 461 -6337 <br /> N Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class A- HAZ <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. 07 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> I <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L ( b a hment With Conditions) f <br /> N Plan Reviewers Name V(d Date / Zq I ZU Z 2 <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, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENS O LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERF, ANTE OF THE WORK 0 WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 1 / <br /> Applicant's Signature G /1 Title Office Manager Date 1 /5/2022 <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 Carrie Mill r-�\, TITLE Office Manager PHONE It (209) 461 -6337 <br /> 1 <br /> ADDRESS 25;5 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE ! l� DATE 1 /5/2022 <br /> 2of6 <br />