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SHAWN Environme l effE <br /> D <br /> _ C0UN -I" Y . ... <br /> APPLICATION FOR UNDERGROUND STORAGE TANK FEB O 8 2023 <br /> RETROFIT OR PIPING REPAIR PERMITFEWRONMENTAL " I ALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BEL6* RM IT / C� ERV IC ES <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller (209) 461 -6337 <br /> � <br /> Facility Name 76 Express Tiger No 1 Phone # (209) 9834781 <br /> I Address 57777 S . French Camp Rd , Stockton CA 95206 <br /> TCross Street <br /> Y Owner/Operator Balbir Singh , Manager Phone # (209) 983-4781 <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 Insurer Midwest Employers Casualty Company Co Work comp # BNUWC0133392 <br /> C <br /> r 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 /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2 , etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name { Date <br /> APPLICANT MUST PERFORM ALL ORK IN ACCORDANC H SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTM 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 /> (� 7V� ..,,,, Office Manager Date 2/8/2023 <br /> Applicant's Signature <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 /> CA f 7, <br /> � <br /> SIGNATURE AA� DATE 2/8/2023 <br /> 2of6 <br />