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SANJOAQUIN Environmental Health Department <br /> -- C0UNTY RECEIVJCD <br /> APPLICATION FOR UNDERGROUND STORAGE TANK APR <br /> RETROFIT OR PIPING REPAIR PERMIT13 <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPk BaOhti � <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTWT1 V <br /> ZI N " <br /> F EPA Site # Project Contact & Telephone # Carrie Miller (209 ) 461 -6337 <br /> C Facility Name SRH Food & Gas Inc . Phone # 209465 -8976 <br /> I <br /> L Address 749 E . Martin Luther King Blvd <br /> Cross Street <br /> T <br /> Y Owner/Operator Muhammad Rizwan Phone # (209 ) 271 -2578 <br /> C Contractor Name Elite IV Contractors Phone # (209 ) 461 -6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr Stockton , Ca 95204CA I is # 1001331 class A <br /> A Insurer Midwest Employers Casualty Company Co Work Comp # BNUWC01 33392 <br /> C <br /> T ICC 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 teak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> LJ (See Attachment With Conditions) <br /> A 2 <br /> N Plan Reviewers Name Date 110t ) <br /> APPLICANT MUST PERFORM AL ORK IN ACCORDANC TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONME TAL HEALTH DFPART0 ICENSED 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 Title Office Manager Date 4/13/2023 <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 Ce 7 DATE 4/ 13/2023 <br /> 2of6 <br />