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Environmental Hclalth C]le a,rtmi rtt <br /> SANIJOAQUIN <br /> APPLICATION FOR UNDERGROUND STORAGE TANK _ <br /> RETROFIT OR PIPING REPAIR PERMIT <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 # Carrie Miller (209) 461 -6337 <br /> C Facility Name Nor Cal Fuels Phone # (209) 227-5008 <br /> I <br /> L Address 3300 West Lane Stockton CA 95204 <br /> Cross Street <br /> T <br /> Y Owner/Operator Carlo Sharmoug Phone # (209) 640-3085 <br /> o 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 InsurerMidwest Employers Casualty Company Co Work comp # BNUWC0133392 <br /> TICC 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 /> (Le, 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 /> LSee Attachment With Conditions) <br /> ) <br /> N Plan Reviewers Name oeo� 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 T�� Tiee Office Manager Date 6/ 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 calle 7d dA4' DATE 6/ 13/2023 <br /> 2of6 <br />