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SR0083601 10/19/21 Amendment for QS 144 <br />SANJOAQUIN Environmental Health Department <br />COUNTY <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYPE BELOW: <br />D TANK RETROFIT ❑ PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Deborah Jones /Administrative Assistant <br />A <br />Facility Name Quik Stop Markets # 144 <br />Phone # (209) 461-6337 <br />I <br />L <br />Address 7272 West Lane Stockton, CA 95210 <br />1 <br />T <br />Cross Street <br />caner pera or w 144 952-88 12 <br />GP <br />Name Elite IV Contractors P hone# <br />0 <br />N <br />Contractor Address 2535 Wigwam Drive Stockton, CA 95205 <br />CA Lic# 1001331 ClassA-Hazmat <br />R <br />InsurerMidwest Employers Casualty Company <br />Work Comp # BNUWC01 33392 <br />I <br />Q <br />r <br />ICC Technician's Name - <br />Expiration Date <br />QR <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 12. etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <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 AGENTS 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 <br />OF CALIFORNIA" <br />Applicant's SignatuiL4CJ4.D/[.t'+1Y Tina Administrative Assistant Data 4/21/2021 <br />U 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 />04/22/2021 <br />2 of <br />