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lQUEnviro � <br /> SAN , uAVI <br /> CCD U N �i Y -- - -.. <br /> JAN 12 2023 <br /> APPLICATION FOR UNDERGROUND STORAG � j I �L) NMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERM i ' FRNI1TISf= RVICES <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 # Project Contact & Telephone # (209) 461 -6337 <br /> A <br /> Facility Name Stop N Shop Phone # (209 ) 941 -2766 <br /> I Address 1856 Country Club Blvd Stockton , Ca 95204 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Nicholas Craggs Phone # (209 ) 981 -3433 <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 InsurerMidwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> T <br /> 0 <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 Attachment With Conditions) <br /> N Plan Reviewers Name Date <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, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <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 �Q/L Title Office Manager Date 1 /12/2023 <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 1 / 12/2023 <br /> 2of6 <br />