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aii le'MicFM1iV <br /> S h H I'N 1 JOAQUIN Environment <br /> -- COUNTY <br /> MAY 0 7 2021 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK HEALTH <br /> H <br /> II.ONMENIAL <br /> RETROFIT OR PIPING REPAIR PERMIT PERNMEN RL HES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> IF EPA Site# Project Contact&Telephone# Deborah Janes 1 Administrative Assistant <br /> Facility Name Quik Stop Markets,#138 Phone# (209)835-8284 <br /> L Address 1153 Lincoln Blvd. Tracy, CA 95376 <br /> TCross Street <br /> Y Ownerf0perator Quik Stop Markets, Inc. Phone#(508) 270-1400 Ext 4469 <br /> c Contractor Name Elite IV Contractors Phone#(209)461-6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Drive Stockton, CA 95205 CA Lic# 1001331 Class q-Hazmat <br /> A Insurer Midwest Employers Casualty Company Work Comp# BNUWC0133392 <br /> C <br /> r ICC Technician's Name Expiration Date <br /> a <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 wmp.91 lookCeieew.UqC 42•etc.} Installed <br /> T �a OGtorQ 10,000 gal <br /> A <br /> N <br /> K <br /> P ❑ Approved u Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name ' Date 5-I 2-G 2 f <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE MWS,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,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 /> Appl;canrssignatur True Administrative Assistant Date 05/07/2021 <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 Deborah Jones TITLE Administrative Assistant PHONE#(209)461-6337 <br /> ADDRESS 2535 Wigwam Drive Stockton,CA 95205 <br /> SIGNATUR DATE 0510712021 <br /> 2oIG <br />