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EnvionmenmSrNtOAUN REUU. IVED <br /> - COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK APR 2 2'92021 <br /> RETROFIT OR PIPING RFPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE . INDICATE PERMIT TYPE BELOW: �AQT ENT <br /> IT <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/E d <br /> F EPA Site # Project Contact & Telephone # Deborah Jones / Administrative Assistant <br /> C Facility Name Quik Stop Markets # 144 Phone # (209 ) 461 - 6337 <br /> L <br /> Address 7272 West Lane Stockton , CA 95210 <br /> I Cross Street <br /> T <br /> Y Owner/OperatorQuik Stop Markets # 144 Phone # (209 ) 952 - 8812 <br /> C Contractor Name Elite IV Contractors Phone # <br /> 0 <br /> T Contractor Address 2535 Wigwam Drive Stockton , CA 95205 CA Lic # 1001331 Class A- Hazmat <br /> A InsurerMidwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> T <br /> T ICC Technician ' s Name Expiration Date <br /> 0 <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 ❑ ApprovedApproved with conditions ❑ Disapproved <br /> L ( erA achment With Conditions) <br /> Aja <br /> N Plan Reviewers Name - T7C r" e Date � / 2 <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 Signature Title Administrative Assistant Date 4/21 /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 I <br /> SIGNATURE L� e+�� DATE 04/21 /2021 <br /> 2of6 <br />