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Environmen al ea t�Depa [yj <br /> SAN IOAQUIN <br /> - --- <br /> COUNTY FEB 2 5 2022 <br /> APPLICATION FOR UNDERGROUND STORAGE TANKIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT PERMIT/SERVICES <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 EPA Site # Project Contact & Telephone # (209 ) 461 -6337 <br /> � <br /> Facility Name 111111111INDBA Parkwood Gas & Food Phone # (209 ) 461 -6337 <br /> I Address 1612 W. Hammer Lane Stockton Ca <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Paul Tiwana & Jessi Phone # (209 ) 888-8156 <br /> C Contractor Name Elite IV Contractors Phone # <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr Stockton CA 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 /> 0 <br /> R ICC Installer' s Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (he, 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 /> Le tta ent With Conditions) <br /> A ti <br /> N Plan Reviewers Name Date�I 12o Z Z <br /> APPLICANT MUST PERFORM ALL WO K INA ORDA TH SAN QUIN COUNTY ORDINANCES, STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENy1RONMENTAL EALT DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE O F THE WORK FO W ICH 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 PE ORMANCE -OF THF, WOR FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signatu ( . C _ , V Tile Office Manager Date 2/24/2022 <br /> LBILLING 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 /> ADDRESS <br /> 2x35 Wigwam Dr Stockton , Ca 95205 <br /> SIGNATURE DATE <br /> 2/24/2022 <br /> 2 of 6 <br />