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v <br />E <br />JOAQUINSAN 1868 E. Hazelton Ave., Stockton, California 95205 <br />SEC <br />Telephone:1•,: .21 i• 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK PERMITISERVICES <br />RETROFIT OR <br />PIPING <br />r r r* PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />•' <br />EPA Site # Project Contact & Telephone # Megan 209-461-6337 <br />C <br />Facility Name Alistar Investments Inc Pnone # 209-321-1632 <br />I <br />L <br />Address 3032 Waterloo Rd Stockton Ca 95205 <br />TCross <br />Street <br />Y <br />owner/operator Dave Singh <br />Phone # 209-321-1632 <br />o <br />Contractor Name Elite IV Contractors <br />Phone # 209-461-6337 <br />N <br />T <br />Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 100331 Class _ <br />A <br />Insurer Midwest Employers Casualty Company work Comp # BNUWC0133392 <br />TICC <br />Technician's Name Expiration Date <br />D <br />R <br />ICC Installer's Name Expiration Date <br />Tank system work area Tank Size Chemicals Stored Currently Date UST <br />Installed <br />p.®. er oft soap, ®1 1„k detector, UDC 1n. ate.) <br />T <br />A <br />N <br />K <br />P ❑ Approved ® Approved With conditions ❑ Disapproved <br />L (See Attachment with Conditions) <br />yy <br />A //�� ii / <br />�tilU�1I� <br />N Plan Reviewers Name rt'l miL Date_ <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: "1 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 />Ap is S tore Tltte Dare <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 Megan Mitchell . TITLE OifjC A �-_PHONE # 209-461-6337 <br />..-SIGNATURE r i <br />Memo , DATE 911812017 <br />EH230038 (revised 12-11-16) 2 <br />