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RE <br /> IVED <br /> ENVIRONMENTAL HEALTH DEPARTMSEP <br /> SAN JOAQUIN COUNTY 3 Z016 <br /> 1868 E. Hazelton Ave., Stockton, California 95`4PkVIRONMENTAL HEALTH <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> DEPARTMENT <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 ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan 209-461-6337 <br /> APhone# 209-937-0195 <br /> O Facility Name Fremont Food Mart <br /> I Address 2185 Fremont Street Stockton Ca 95205 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Joe Loa TPhon=e# 209-937-0195 <br /> CContractor Name Elite IV Contractors e# 209-461-6337 <br /> O <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic# 1001331 Class A-HAZ <br /> T <br /> R Insurer Midwest Employers Casualty Company Work Comp#l3NUWC0133392 <br /> A <br /> T ICC Technician's Name Expiration Date <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.UCC 12.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P El Approved `Approved with conditions _ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name � �i �k �\�� 4, Date <br /> �— <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 AGENTS 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." <br /> Applicant's Signa tur Tide Office Assistant Date 9129/2016 <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 /> g <br /> NAME <br /> Megan Mitchell TITLE Office Assistant PHONE# 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE rrle DATE 9/29/2016 <br /> EH230038(revised 12-11-15) 2 <br />