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SAN l U A Q U I N Environmental Healh rm IV E D <br /> C OUNT1' . . . _ .. <br /> DEC 12 2023 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT PERMIUSERVICES <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 /> C Facility Name BlackHawk Petroleum Inc Phone # 209-913-2942 <br /> L <br /> Address 5611 E . Waterloo Rd . Stockton <br /> TCross Street <br /> Y Owner/Operator Lubna Hussain Phone # 408-515-3380 <br /> C Contractor Name Elite IV Contractors Phone # 209 -461 -6337 <br /> 0 <br /> IN <br /> T Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class q <br /> A Insurer Midwest Employers Casualty Company Co Work Comp # BNUWC0133392 <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 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See At achment With Conditions) <br /> N - - <br /> Plan Reviewers Name C - � 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." ��'�- Q� , <br /> Applicant's Signature C i �'k�` Title Office Manager Date 10/ 10/2023 <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 10/ 10/2023 <br /> 2 of 6 <br />