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SANJOAQUIN Environmental Health Department <br /> - COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TAM <br /> RFTROFIT� OR PIPING REPAIR PERM IT <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 # Carrie ( 209) 461 - 6337 <br /> C Facility Name Quik Stop 76 Phone # (209 ) 464- 1038 <br /> I <br /> L Address 1030 S . Olive Ave Stockton CA 95215 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Quik Stop Markets Phone # (209 948 -6731 <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 /> 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 /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc. ) Installed <br /> T <br /> A <br /> N <br /> K <br /> P El Approved Approved with conditions ElDisapproved <br /> L (Spd7t chment With Conditions) <br /> A <br /> N Plan Reviewers Name6� Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE' ITH 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 ` 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 COMPENSAj ION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFOR ANdE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> approe �rs Signature ��ili�%ALL F /F ) . / ' 61 : Tale Office Manager Dale 2/ 15/2022 <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 /> ADDRESS 253 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE �t/ ! `� � C�f DATE 2/ 15/2022 <br /> 2of6 <br />