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i <br /> I <br /> ENVIRONMENTAL HEALTH DEPARTMi � � � „r <br /> SAN JOAQUIN COUNTY APR 2 7 2016 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 D PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Terry Masters 209-461-6337 <br /> A <br /> C Facility Name ARP MINI MART CORP Phone# 209-835-7777 <br /> i Address <br /> L 25775 S.Patterson Pass Rd Tracy 95377-9717 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Ron Patel Phone# 510-316-6580 <br /> c Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> N Contractor Address 2535 Wigwam Dr Stockton CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Casualty work Comp# BNUWC0133392 <br /> T <br /> T ICC Technician's Name Expiration Date <br /> ° <br /> R ICC Installer's Name Expiration Date <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 /> I Approved with conditions ❑ Disapproved <br /> P i Approved 1�C <br /> L (See Attachment With Conditions) <br /> A L� <br /> N Plan Reviewers Name -y / t DateL-Mmiz't _�2 -2O 1 <br /> ij <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CO 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 PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' r�i� <br /> Applicant's Signature (?,Z I"� Title Office Manager Date 4/27/16 <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 Carrie Miller- Elite IV Contractors TITLE Office Manager PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE DATE 4/27/16 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />