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SAKJ <br /> f1 ( � <br /> CO ��jJ FD <br /> Environmental Health epa in n <br /> N -� �. _ _. _ MAY 0 6 2022 <br /> APPLICATION FOR UNDERGROUND STORAGE TENIARONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTJEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller (209) 461 -6337 <br /> C Facility Name Delta Arco Phone # (209) 465-2487 <br /> I Address 440 W. Dr Martin Luther King Jr Blvd Stockton , CA 95206 <br /> L <br /> TCross Street <br /> Y Owner/Operator Major Singh Phone # (209) 594-2100 <br /> 0 <br /> Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <br /> ."r Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class A <br /> A Insurer Midwest Employers Casualty Company Work comp # BNUWC0133392 <br /> C <br /> T ICC Technician' s Name Expiration Date <br /> R <br /> R ICC 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 Approved with conditions ❑ Disapproved <br /> L (Se ttachment With Conditions) <br /> A <br /> N Plan Reviewers NameLDate—_-- a k7 Z _ <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 AGENTS 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 SUBJECT TO <br /> WORKER'S COMPENSA ON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFO CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature " �'�' Title Office Mana ger Date 5/6/2022 <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 25 WI warn Dr Stockton , Ca 95205 <br /> SIGNATURE ! I� � 80 DATE 5/6/2022 <br /> 2of6 j <br />