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SAN JOAQUIN <br /> Environmental Health Department <br /> - - - - C O l J N T Y - ._...._. <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIP NG REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW: <br /> ❑ `f'ANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # (209 ) 461 -6337 Carrie Miller <br /> � Facility Name Orlandos Phone # (209 ) 887- 1100 <br /> I Address 18754 S . HWY 26 , Linden Ca 95236 <br /> L <br /> TCross Street <br /> Y Owner/Operator Sam Orlando Phone # (916 ) 708 -4999 <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 <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> TICC 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 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions ❑ Disapproved <br /> L Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Ott r ' Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA NTH 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 SUBJECTTO <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 Title Office Manager Date 8/ 18/20222 <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 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE DATE 8/ 18/20222 <br /> 2of6 <br />