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Environni D E+VFU <br /> SAN MOWN REC <br /> JUN 1 / 19 2021 <br /> APPLICATION EOR UNDERGROUND STORAGE TANK <br /> RETR® F � ' 1i ' OR V F1 \105 P EP�� I '�' �-IN -Z WIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: DEPARTMENT <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> � Facility Name G S G Gas & Mart Phone # 209-467-0305 <br /> I <br /> L Address 701 E . Charter Way Stockton CA 95206 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Swaran Chouhan Phone # 209-993 - 1298 <br /> C Contractor Name Elite IV Contractors Phone # 209 -461 -6337 <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr Stockton CA 95205 CA Lic # 1001331 Class A , HAZ <br /> T <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> C <br /> T ICC Technician 's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i,e. 87 piping sump, gt leak detector, UDC 1124 etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved , pproved with conditions ❑ Disapproved <br /> L S(Seoehment With Conditions ) <br /> N Plan Reviewers Name / Date �Y <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE� WR 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 OFT 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 COMPENSATI N AWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA CE 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 1 ' � ' I " Title Office Manager Dale 6/ 18/2021 <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 /> Carrie Miller Office Manager209-461 - 6337 <br /> NAME TITLE PHONE # <br /> i <br /> ADDRESS 2535 Wigw2nr Stockton , Ca 95205 <br /> SIGNATURE ALL kAolDATE P <br /> I <br /> I <br /> i <br /> 2of6 j <br /> { <br />