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S A N JOAQUIN <br /> OAQ IN Environmental Health Department <br /> - - COUNTY---- <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 /> O TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Carrie Miller(209) 461-6337 <br /> o Facility Name Jamar Service Phone#(209)464-1431 <br /> I <br /> L Address4075 E. Main Street Stockton, CA 95215 <br /> 1 Cross Street <br /> T <br /> v Owner/Operator Lori Toccoli Phone# (209)483-2533 <br /> Q Contractor Name Elite IV Contractors Phone#(209) 461-6337 <br /> 0 <br /> T Contractor Address2535 Wigwam Dr Stockton, Ca 95205 CALic# 1001331 Class A <br /> A Insurer Midwest Employers Casualty Company Work Comp#BNUWC01 33392 <br /> c [CC Technician's Name Expiration Date 10/01/2025 <br /> T <br /> 0 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 leek detector,UDC 1Q.etc) Installed <br /> T 91 Fill Bucket <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 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,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."Applicant's Signature (/7a4 /,Qwk&IZ41 Title Office Manager Date 5/22/25 <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 /> NAMECarrle Miller TITLE-Office Manager PHONE#(209) 461-6337 <br /> ADDRESS2535 Wigwam Dr Stockton, Ca 95205 <br /> ` a4, n <br /> SIGNATURE `� � 7rVA4 DATE 5/21/25 <br /> 2 of <br />