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SAN JOAQUIN <br />.COUNTY-_ <br />Environmental Health Department <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING 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 <br />EPA Site # <br />Project Contact 6celephone if Carrie Miller (209) 461-6337 <br />� <br />Facility Name Quik Stop 144 <br />Phone # 209-952-8812 <br />I <br />Address 7272 West lane Stockton, CA 95210 <br />L <br />1 <br />Cross Street <br />T <br />Y <br />-Owner/Operator-Gumberland-Farms-/-EG-Americ-a <br />-Phone # <br />C <br />Contractor Name Elite IV Contractors <br />Phone # 209-461-6337 <br />O <br />N <br />Contractor Address 2535 Wigwam Dr Stockton <br />CA Lic # 1001331 Class A Haz <br />A <br />Insurer Midwest Employers Casualty Company <br />Work comp # BNUWC0133392 <br />C <br />ICC Technician's Name <br />Expiration Date <br />T <br />o <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(Le, 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />e Attachment With Conditions) <br />A <br />N <br />/2 <br />Plan Reviewers Name Date h� <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 COMPENSAT LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORM NqE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." // <br />11MILLI Office Manager 11/24/21 <br />Applicant's Signature Till, Date <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 Carrie Miller TITLE Office Manager PHONE # 209-461-6337 <br />253ig am Dr Stockton, Ca 95205 <br />ADDRESS <br />,V4 r%A7C 11/24/21 <br />JI VIVMI V <br />2of6 <br />