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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY L � <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 1 -1 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TWE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT O COLD START/EVR UPGRADE <br /> F EPA Site X Project Contac 8 Telephone a Megan Mitchell 209-461-6337 <br /> � Facility Name Arco AMpM Phone M <br /> 209-599-7600 <br /> � Address 1340 Colony Rd Ripon Ca <br /> I <br /> T Cross Street <br /> y Owner/Operator Ranjeet Singh Phone p 209-579-4014 <br /> D contractor Name Elite IV Contractors Phone k 209-461-6337 <br /> 0 <br /> T Contractor Address 2 3 i wam Dr k n CA Lie R 1001331 Class A-HAZ <br /> A insurer Midwest Employers Casualty Company work comp#MBUWC0133392 <br /> D <br /> T ICC Technician's Name Expiration Date <br /> D <br /> R ICC Installers Name Expiration Date <br /> Tank system Work area Tank Size Chemicals Stored Currently Date UST <br /> 0.,m wano...m.01 it corm,Loc 12,r I Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved With Conditions D Disapproved <br /> L (AA chment With Conditions) <br /> AP�IQ � vl�o 0-1(A <br /> N Plan Reviewers Name Date <br /> MUST PERFORM ALL WORK N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> jOAOUIN COUNry.FwlRONMEMAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SKsNATURE CERTIFIES THE FOLLOWING: Y CERTIFY THAT N <br /> IE PERFORMAINCE 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' CONTRACTORS 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 /> Apglcert'f SlWw" nae OffiCe Deb 9/14/2016 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the parry must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Megan Mitchell __ _._ TITLE Office Assistant PHONE n 209-461-6337 <br /> ADDRESS 2535 Wigwam <br /> /�Q�[Stockton Cal 95205 <br /> RE__ _ <br /> SIGNATUU //L �'noOO __._. _ DATE 9/14/2016 _ <br /> ER230038(mvised l2-11-15) (� 2 <br />