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SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT U PIP1V Giv 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 ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones (209) 461 -6337 <br /> C Facility Name VANCO Truck & Auto Plaza Phone # (209) 466 - 0833 <br /> L Address 1033 W Charter Way Stockton , CA 95206 <br /> Cross Street <br /> T <br /> Y Owner/Operator Mike Popari Phone # (209) 466 - 0833 <br /> C Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <br /> 0 <br /> N Contractor Address 2535 Wigwam Drive Stockton , CA 95205 CA Lic # 1001331 Class A-Hazmat <br /> A Insurer Midwest Employers Casualty Company Work comp # BNUWC0133392 <br /> T ICC Technician 's Name Joseph Bartholdi #2851 Expiration Date 4/ 13/2023 <br /> R ICC Installer's Name Joseph Batholdi #2851 Expiration Date 4/ 13/2023 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 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 ( e achment With Conditions) <br /> A kL / <br /> 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, 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 i <br /> OF CALIFORNIA." <br /> r <br /> Applicant's Signatur6 AAdministrative Assistant 9/ 14/2021 <br /> � Ti <br /> .��-��� tle Date <br /> f <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 Elite IV Contractors TITLE Contractor PHONE # (209 ) 461 - 6337 1 <br /> ADDRESS 2535 Wigwam Drive Stockton , CA 95205 i <br /> SIGNATURE z f/4 ���ak. � DATE 4/ 19/2021 <br /> C <br /> 2of6 <br />