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SAN I O A (, U IN <br /> Environmental Health Department <br /> SAN : <br /> O U N T Y - <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 ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209461 -6337 <br /> A <br /> C Facility Name JD Service Station Phone # <br /> I Address 9015 W Walnut Grove Rd Thornton Ca 95686 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Jawinder Singh Phone # 209-794-8993 <br /> C Contractor Name Elite IV Contractors Phone # 209461 -6337 <br /> O <br /> T Contractor Address 2535 Wigwam Or Stockton Ca 95205 CA Lic # 1001331 Class A-HAZ <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> C <br /> T ICC 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 112 , etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ' Approved with conditions ❑ Disapproved <br /> L See Attachment With Conditions ) <br /> A RZ <br /> N Plan Reviewers Name Date. I I y' I I C1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J QUIN 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 /> tt <br /> i <br /> Asssan <br /> Applicant's Signature Title Office Date <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e .g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Megan Mitchell TITLE Office Assistant PHONE # 209461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 95205 <br /> SIGNATURE /r`� DATE Cil /✓ // <br /> 2 of 6 <br />