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SANW I Environmental Hemltti Depar'r. Inent <br /> C Ci l_1 1\1 -1 , Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIRPERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/ RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller ( 209 ) 461 -6337 <br /> A ----- - <br /> C Facility Name Manteca Gas & Food Phone # 209-239 -2233 <br /> Address 1229 E , Louise Ave Manteca CA 95336 <br /> L <br /> TCross Street <br /> Y Owner/Operator Jesse Singh Phone # 209-814- 3730 <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 /> TICC Technician' s Name Expiration Date <br /> 0 <br /> R ICC Installer' s Name Expiration Date <br /> Tank system work areaDate UST i <br /> Tank Size Chemicals Stored Currently <br /> (i,e. 87 piping sump, 91 leak detector, UDC 112, etc. ) Installed <br /> T -- <br /> A <br /> N -- <br /> K � <br /> --i <br /> P ❑ Appr ved Approved with conditions ❑ Disapproved <br /> i <br /> L (S A achment With Conditions) <br /> A �N Plan Reviewers Name Date 12,1 1 q <br /> APPLICANT MUST PERFORM ALL WORK IN AC D ANCE 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 i <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 I <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY i <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 /> Office Manager Date 12/01 /2023 <br /> Applicant's Signature Title <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 /> 2535 Wigwam Dr Stockton , Ca 95205 <br /> ADDRESS <br /> SIGNATURE C4Ll.,Q 7e - _i DATE <br /> 2of6 <br />