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SA N. 10 A Q U I N Environmental Health Department <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 0 PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT C COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Carrie (209) 461-6337 <br /> A <br /> C Facility Name El Dorado Food Malt Phone# (209)461-6337 <br /> I Address 2320 N. Et Dorado St. Stockton <br /> L <br /> Cross Street <br /> Y OwnerlOperator Patil Oil Company- Rick Phone#209-495-7641 <br /> o Contractor Name Elite IV Contractors Phone# (209)461-6337 <br /> T Contractor Address2535 Wigwam Dr Stockton, Ca 95205 CALic# 1001331 Class A <br /> R InsurerOak River insrance Company Work Comp# ENWC625807 <br /> A <br /> T <br /> T ICC Technician's Name Expiration Date <br /> 0 ICC Installer's Name Expiration Date <br /> a R <br /> Tank system work area Tank Size Chemicals Stared Currently Date UST <br /> ji.e.87 piping sump,91 leak defector.UDC 112,e1c.) Installed <br /> T UDC`s#1/3,#2/4, #517#618 <br /> A <br /> N <br /> K <br /> P [X] Approved with conditions '_� Disapproved <br /> L (See Attachment With Conditions) <br /> A _ <br /> N Plan Reviewers Name gate 07/0712026 <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 CALIFCRNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FCLLOVVING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FCR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." //'� (/ <br /> Applicant's Signalwe V? � / l� Title Office Manager Date 6/19/2026 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHO 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 Kennard TITLE Office Manager PHONE*209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE ---DATE 6/19/2026 <br /> 3afa <br />