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SAN1 O f� 011 I N E= nvironmental Health Department <br /> C0Ur�!1Iy _ . . <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 100 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 it Deborah Jones Administrative Assistant <br /> C Facility Name Quik Stop Markets # 132 Phone # (209 ) 951 -3195 <br /> I <br /> L Address 3555 W Hammer Lane Stockton , CA 95209 <br /> 1 Cross Street <br /> T <br /> Y Owner/OperatorQuil< Stop Markets , Inc . Phone # ( 508 ) 270- 1400 Ext 4469 <br /> C Contractor Name Elite IV Contractors Phone # ( 209) 641 - 6337 <br /> O <br /> T 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 /> 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 (See ttaphment With Conditions) <br /> N Plan Reviewers Named Date <br /> ) <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 i <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:' /) Jj <br /> Applicant's Signatu � '?Jit)If JD�/ TiUe Administrative Assistant Date 5/06/2021 <br /> BILLING INFORMATION : <br /> { <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. i <br /> NAME Deborah Jones TITLE Administrative Assistant PHONE # (209) 461 -6337 <br /> ADDRESS 2535 Wigwam Drive Stockton , CA 95205 <br /> SIGNATURE �� 1 Y! t?1j�� DATE 5/06/2021 <br /> i <br /> I <br /> I <br /> 2of6 <br />