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} N �( �,� Environmental Health Department <br /> t J4 i ' <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 /> H TANK RETROFIT ❑ PIPING REPAIR/RETROFIT fI UDC REPAIR/RETROFIT n COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller ( 209 ) 461 -6337 <br /> � Facility Name Wight Holdings Inc . Phone # 209-478 -5552 <br /> Address 2908 W. Benjamin Holt Dr . Stockton 95207 <br /> Cross Street <br /> T <br /> Y Owner/Operator Lawrence Wight Phone # 209 - 993- 7825 <br /> C Contractor Name Elite IV Contractors Phone # 209-461 - 6337 <br /> 0 <br /> 1" 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 /> 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 i '_� Approved with conditions �_� Disapproved <br /> L (SelAttachment With Conditions) <br /> A <br /> N Plan Reviewers Name I Date? �1 <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." /f// <br /> Applicant's Signature / / /12� Title Office Manager Date 2/ 16/2024 <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 2/ 16/2024 <br /> 2of6 <br />