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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 APR 01 2015 <br /> APPLICATION FOR UNDERGROUND STORAGE TANKENVIR®NMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT MFAITwn=vAoTA,trniT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Kim 209-46 6337 <br /> � Facility Name Arch Arco AM PM I Phone# 09-948-2438 <br /> I <br /> L Address 4855. HWY 99 Frontage Rd. <br /> I Crass Street <br /> T <br /> Y Owner/Operator Jivtesh Gill one# 948-2438 <br /> D Contractor Name Elite IV Contractors Phone# 461-6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr. CA #66076 Class ABC10HAZ <br /> R Insurer Markel work Comp# MWC0070230 <br /> A <br /> Q ICC Technician's Name Expiration Date <br /> T <br /> o ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (Se chment Wth Conditions) <br /> A <br /> N Plan Reviewers Name Date �46Ji <br /> APPLICANT MUST PERFORM ALL WORK IN CORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEA H DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR ICH 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 ALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE RK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant's Signature Carrie ' ler Title Office Manager Date 4/1/2015 <br /> BILLING INFORMATION: <br /> Indicate the responsi a party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designa d below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for a billin by si nature and date below. <br /> NAME TITLE PHONE# <br /> Carrie iller - lite IV Contractors Office Manager 209-461-6337 <br /> ADDRES 2535 Wigwam Dr. <br /> 4/1/LU1b <br /> SIGNA URE -- = DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />