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(° t { (� I Environmental Health Department <br /> J- COUNTY-__._ <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 D COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan M 209461 -6337 <br /> CFacility Name Fnigt Lane Gas & food Mart Phone # 707-326-0369 <br /> I Address 116 Roth Rd Lathrop Ca 95330 <br /> L <br /> TCross Street <br /> Y Owner/Operator Hardeep Phone # 707"326-0369 <br /> c Contractor Name Elite IV Contractors Phone # 209461 -6337 <br /> O <br /> N Contractor Address 2635 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A-HAZ <br /> T <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> T <br /> T ICC Technician's Name Expiration Date <br /> R <br /> ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 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 Tea: It <br /> (� /�� g <br /> N Plan Reviewers Name � , 1 iAIJ )a^ 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: 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 /> Applicant's Signature J�Z c Title Office Assistant Date 1 1 <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 StocktonCa 95205 <br /> - <br /> SIGNATURE 4&4 DATE <br /> 2 of 6 <br />