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SA N . 1 U 0 I N Envirornnlental Health Department <br /> C 0 L-i 1`.t'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 /> D TANK RETROFIT n PIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT ❑COLD 5T'ARTIEVR UPGRADE <br /> F EPA Site# Projeet Contact&Telephone#Carrie Miller(209)461-6337 <br /> Facility Name A&A Gas Inc. Phone#(209)466-9516 <br /> L Address 16 E. Harding Way Stockton, CA 95204 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Mohammed Phone#{209)707-5749 <br /> o Contractor Name Elite IV Contractors Phone#(209)461-6337 <br /> T Contractor Address 2535 Wigwam Dr Stockton, Ca 95205 CA Lic##1001331 Class A <br /> A Insurer StarNet Work Camp#BNUWC0133392 <br /> T ICC Techniclan's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date LIST <br /> (l.e-87 PIPing sump.911eak detector,VDC 112,elc,y Installed <br /> T Diesel Leak Detector <br /> A <br /> IN <br /> K <br /> P Approved with conditions ❑ Disapproved <br /> L [ e A chment With Conditions) <br /> A <br /> N Plan Revlewers Name Date 8122125 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUiN COUNTY ORO]NANCES,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 LN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNW* CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWNG: "I CERTIFY <br /> THAT tN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Appllcanrs Signature CZ12z � 71-pk� T*Office Manager bale 7131125 <br /> BILLING INFORMATION- <br /> Indicate the responsible party to be billed for additional E H D staff time expended beyond parmIt 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) 461-5337 <br /> ADDRESS 2535 Wigwam Dr Stockton, Ca 95205 <br /> SIGNATURE � . DATE 7/31/2025 <br /> 3 nT ti <br />