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SA I rA A ("I U I N Environmental Health Department <br /> __ ... . C- C.) U 1\1 T Y _. _ <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 REPAIRIRETROFIT ❑ UDC REPAIR/ RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller ( 209) 461 -6337 <br /> A Faci! it Name MCM 14 CORP - Arco Phone # 209 466-6633 <br /> C <br /> . y ( ) <br /> L Address 130 Wilson Way Stockton , CA 95205 <br /> Cross Street <br /> T <br /> Y Owner/OperatorRinku Phone # ( 916 ) 607-3245 <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 q <br /> A InsurerMidwest Employers Casualty Company Co Work Comp # BNUWC0133392 <br /> 0 <br /> T ICC Technician' s Name Expiration Date <br /> 0 <br /> R ICC 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 1 /2, etc. ) Installed <br /> T <br /> (marl ) ( Qqu ► ar �anwc w ► � z � ( Cie <br /> N �'I tranµ (�tph� �) reyuiur unjWM t Iz2 ( q ?) 9 <br /> K q tanµ <br /> rr � mlvrr, un1�cK.l (� 1 122 / ( gtii3 <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name Date 2 ' Z 3 rLGLy <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 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 />