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SANJOAQUIN I Environmental Health Department <br /> COI JNTY - <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 0 UDC REPAIR/RETROFIT 0 COLD STARTIEVR UPGRADE <br /> IF EPA Site # Project Contact & Telephone # Carrie Miller (209 ) 461 -6337 <br /> A Facility Name Ernies General Store Phone # 209-931 -2850 <br /> I <br /> L Address 4407 E . Waterloo Rd Stockton CA 95215 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Ernest Giannechini Phone # 209 -931 -2850 <br /> c Contractor Name Elite IV Contractors Phone # (209) 461 - 6337 <br /> N Contractor Address 2535 Wigwam Dr Stockton CA 95205 CA Lic # 1001331 Class A , HAZ <br /> T <br /> A Insurer Midwest Employers Casualty Company Work comp # BNUWC0133392 <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 /> (Le, 87 piping sump, 91 leak detector, UDC 1 /20 etc.) Installed <br /> T <br /> A <br /> N <br /> I< <br /> P ❑ Approved roved with conditions ❑ Disapproved <br /> L (See ach ent With Conditions) <br /> A 14 <br /> N Plan Reviewers Name Dates <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENV IQNMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE 0 TH 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 COMPEN TIO LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFO MAN E OF THE WORT OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA:' <br /> Applicant's Signature Tifle Office Manager Date 209- 461 -6337 <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 Carrie Wffer - Elite IV Contractors TITLE Office Manager PHONE # 209-461 -6337 <br /> ADDRESS 535 YiVigwarn Dr St t CA 95205 <br /> r / / 0 &/L I <br /> SIGNATURE DATE 5/25/2021 <br /> 2of6 <br />