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RECEIVED <br /> SANIJOAUUIN Environmental Health Department <br /> C 0 (J N "T Y FEB 0 0 2024 <br /> APPLICATION FOR UNDERGROUND STORAGE TA60 VIRONMENTAL HEALTH <br /> RETROFIT OR PIPINGAIR PERMIT PERMIT/ SERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller 209-461 -6337 <br /> � <br /> Facility Name Manteca Liquor & Food Phone # ( 209 ) 2394550 <br /> 1 <br /> L Addressg90 N . Main St . Manteca Ca 95336 <br /> TCross Street <br /> Y Owner/OperatorJeet Sandhu Phone # (209 ) 765-2619 <br /> C Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <br /> O <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 # BN UWC01 33392 <br /> C <br /> T ICC Technician 's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (1,e, 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 /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name. ,45 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, 1 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 (? 71/a� Title Office Manager Date 2/6/2024 <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 Ca4l .Q i &� DATE 2/6/2024 <br /> 2of6 <br />