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i <br /> ENVIRONMENTAL HEALTH DEPARTMENT, , <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 JUL 13 2016 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> I <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# , _ Project Contact&Telephone# 209-461-6337 <br /> C Facility Name Phone# 209-835-$284 <br /> Q,lick Stoo <br /> Address 1153 Lincoln Way Tracy Ca 95376 <br /> TCross Street <br /> Y Owner/Operator Quick Stop Markets Inc Phone# 800-972-0982 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> T Contractor Address 2535 Wi wam Dr Stockton Ca 95205 CA Lic# Class A-HAZ <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> TICC Technician's Name Expiration Date <br /> RICC 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 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> i <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A achment With Conditions) <br /> A <br /> NMa r) <br /> Plan Reviewers Name n 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: "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 Signature <br /> Title Office Assistant Date 7/13/2016 <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 /> NAME Megan Mitchell TITLE Office Assistant -PHONE# 209-461-6337 <br /> I <br /> ADDRESS 2535 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE ;Z /?` /2 DATE 7/13/2016 <br /> EH230038(revised 12-11-15) 2 <br /> I <br />