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ENVIRONMENTAL HEALTH DEPARTME Lw� <br />SAN JOAQUIN COUNTY :JUN 22 2016 <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 `4'b\hg` <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 ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact &Telephone # Carrie Miller (209) 461-6337 <br />A <br />C <br />Facility Name Super Center Mart <br />Phone # 209-467-0305 <br />I <br />L <br />Address 701 E. Charter Way <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator Swaran Chouchan <br />Phone # 209-993-1298 <br />C <br />0 <br />Contractor Name Elite IV Contractors <br />Phone # <br />T <br />Contractor Address 2535 Wigwam Dr Stockton CA 95205 <br />CA Lic # 1001331 Class A.HAZ <br />A <br />insurer Midwest Employers Casualty Company <br />Work Comp # BNUWC0133392 <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />o <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, uoc 1n. etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved with conditions ❑ Disapproved <br />L <br />LAproved <br />Shment With Conditions) <br />N <br />Plan Reviewers Name Date___.._. l <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 PERN41T IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature �� Title Office Manager Date 6/22116 <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 Contractors TITLE Office Manager PHONE# 209-461-6337 <br />ADDRESS 2535 Wigwam Dr Stockton CA 95205 <br />SIGNATURE 1444zo i%�1L��4n� DA <br />EH230038 (revised 07-17-2014) <br />6/22/16 <br />