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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <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 />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Megan M 209-461-6337 <br />�Facility <br />Name Waterloo Food Mart <br />Phone # _ -3674 <br />Address 4315 E Waterloo Rd Stockton Ca 952,,1 5 <br />T <br />Cross Street <br />Y <br />Owner/Operator Rupi Padda <br />Phone# 209-931-3674 <br />C <br />Contractor Name Elite IV Contractors <br />Phone # 209-461-6337 <br />0 <br />N <br />Contractor Address 2535 Wigwam Dr Stockton Ca 95205 <br />CA Lic # 1001331 Class A-HAZ <br />T <br />A <br />Insurer Midwest Em to ers Casualty Company <br />Work Comp # BNUWC0133392 <br />TICC <br />Technician's Name <br />Expiration Date �f~ <br />0 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemic Stored Currently Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />T <br />A <br />K01 <br />rRNV1R. NM N"rAi,in <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L <br />A <br />(Stachment With Conditions) <br />N <br />Plan Reviewers Name Date �g g <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: "1 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." <br />(k4 <br />Applicant's Signature Title Office Assistant Date <br />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 />Megan Mitchell TITLE Office Assistant PHONE# 209-461-6337 <br />2535 Wiqwam Dr Stockton Ca 9520; <br />SIGNATURE 7e44?-- f'�7PDATE <br />61 <br />EH230038 (revised 12-11-15) <br />