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SN { O A Q U i N Environmental Health Dieparttm' nt <br /> COL) NTY - I � <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 /> 0 TANK 'RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones 209 461 -6337 <br /> A Facility Name Phone # 209 941 -2264 <br /> c v My Mini Mart ( ) j <br /> Address 1756 N Wilson Way Stockton , CA 95205 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Ashish Boveja Phone # ( 209 ) 941 -2264 <br /> C Contractor Name Elite IV Contractors Phone # <br /> O <br /> T" CA Lic # 1001331 class A- Hazmat <br /> . Contractor Address 2535 Wigwam Drive Stockton , CA 95205 <br /> A Insurer Midwest Employers Casualty Company Work comp # BNUWC0133392 <br /> c <br /> T ICC Technician 's Name Expiration Date <br /> Q <br /> R ICC 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 ( chment With Conditions) <br /> A � �N Plan Reviewers Name Date <br /> i <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 Signat Title Administrative Assistant Date 4/02/2021 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EH D 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 Deborah Jones TITLE Administrative Assistant PHONE # ( 209 ) 461 -6337 <br /> ADDRESS 2535 Wigwam Drive Stockton , CA 95205 <br /> SIGNATURE DATE 4/02/2021 <br /> 2of6 <br /> I <br /> I <br />