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• <br /> ENVIRONMENTAL HEALTH DEPARTI�. 6EIVED <br /> SAN JOAQUIN COUNTY ��tt�� <br /> 1868 E. Hazelton Ave., Stockton, California 95205 FEB 1 1 2016 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT HEAITH DF 4RTMFNT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# Teary Masters 209461-6337 <br /> C Facility Name Arch Arco AM PM Phone# 209-948-2438 <br /> I <br /> L Address 4855 S. HWY 99 East Frontage Rd. Stockton <br /> I Cross Street <br /> Y Owner/Operator Jlvtesh Gill Phone# 209.481-7445 <br /> G Contractor Name Elite IV Contractors Phone# <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr.Stockton CA Lir# 1001331 Class A-HAZ <br /> T <br /> R Insurer Midwest Employers Casulit y Company Work Comp# BNUWC0133392 <br /> A <br /> G ICC Technician's Name Expiration Date <br /> 7 <br /> 0 ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> e.m piping sump,91 leak peal UDC In.M) Installed <br /> Q <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> JA <br /> (S Attachment With Conditions) <br /> lan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACC CE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> HE 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 /> RTIFY <br /> WORKERS <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISS ED,ING ,II SMALL OEMPLOY PERNTRACTING SONS SUBJECT TO WORKERS COGNATURE CERTIFIES THE MP NSATIONLAWS <br /> OF CALIFORNIA.' n <br /> p'} Title Office Manager Data 2111/16 <br /> Appncenrs Signature (J, <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 party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Elite IV Contrcators-Carrie Miller TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton CAnn A�� <br /> SIGNATURE ( aA.1 ?9dA4. DATE 211116 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />