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SAN10 A G U IN Environmental Health Department <br /> - - - COU NTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANI <br /> RETROFIT OR PIPING RFPA P. PPRMIT <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 It Project Contact & Telephone # Carrie Miller ( 209) 461 -6337 <br /> C Facility Name Adelfos Inc . Arco # 83849 Phone # (209 ) 601 -7292 <br /> 1 Address 3443 Cherokee Rd Stockton CA 95205 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Richard Sarris Phone # ( 209 ) 570- 8976 <br /> C Contractor Name Elite IV Contractors Phone x( 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 /> 0 <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 /> ti.e. 87 piping sump, 91 leak detector, UDC 112, etc. ) Installed <br /> T <br /> A <br /> N <br /> I< <br /> i <br /> i <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N2 Reviewers Name Date ( � 2 202 <br /> I <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 9F 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 VOR <br /> LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFO MANCE OF THE ORKTR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." V <br /> I <br /> Applicant's Signature <br /> C�h 'l 't� 1 � Title Office ManagerDate 1 / 12/2022 <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 Miller. TITLE Office Manager PHONE # ( 209 ) 461 -6337 <br /> ADDRESS 2535 igWam Dr Stockton , Ca 95205 <br /> SIGNATURE L ` T/ L DATE 1 / 12 /2022 <br /> 2of6 <br />