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SANM A Q U IN Environmental Health Department <br /> - -- C O U N T Y -- - - - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209-461 -6337 <br /> A <br /> C Facility Name B&G Group Phone # 707-326-0369 <br /> I <br /> L Address 116 Roth Rd Lathrop Ca 95330 <br /> I Cross Street <br /> T <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 2535 Wigwam Dr Stockton Ca 95205 CA LIC # 1001331 Class A-HAZ <br /> T <br /> R Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> A <br /> C <br /> T ICC Technician's Name Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. B7 piping sump, 91 leak detector, UDC 12, 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 . <br /> N Plan Reviewers Name 1QZW1AA " � 1 earn" ir ' 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 Tie. Office Assistant Date C <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 # 209.461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton Ca 9572,,05 <br /> SIGNATURE i tt " DATE <br /> 2 of 6 <br />