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SANOA Q U I N Environmental Health Department <br /> - -- C 0UN11Y ' V <br /> APPI_GA d Iom rove L>IRIIJ1GROUND STORAGE TANK <br /> Va° G ) E ) V= C ' � V ' � V��9 : G� �� O � P 6IMIT <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 (209) 461 -6337 <br /> C Facility Name Woodbridge AmPrn Phone # ( 209 ) 339 - 8238 <br /> 1 Address 18806 N . Lower Sacramento Rd Woodbridge 95258 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Jas' s Enterprise Phone # (209 ) 339 -8238 <br /> C: Contractor Name Elite IV Contractors Phone # ( 209 ) 461 -6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class A <br /> A lnsurerMidwest Employers Casualty Company Work Comp # 13NUWC0133392 <br /> T <br /> T ICC Technician ' s Name Expiration Date <br /> 0 ICC Installer's Name p <br /> R 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 ( tachment With Conditions) <br /> N Plan Reviewers Name _ Date �aZ�77 2�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, EN RONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANC F E 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 COMP SATI N LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PER ORMA CE OF THE WOR OR71CH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA:' � �1�J WWW <br /> Applicant's Signatu Title Office Manager Date 5/9/2022 <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 igwa Dr Stockton , Ca 95205 <br /> SIGNATURE � DATE 5/9/2022 <br /> 2of6 <br />