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SAN JD AU I N Environmental Health Department <br /> C. 0U NTY . <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> XTANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD sTARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # (209) 461 -6337 <br /> C Facility Name Manteca Gas and Food Phone # (209) 239-2233 <br /> I <br /> L Address 1229 E . Louise Ave Manteca CA 95336 <br /> TCross Street <br /> Y owner/operator Jessie Singh Phone # (209) 814-3730 <br /> 0 <br /> Contractor Name Elite IV Contractors Phone # (209) 461 -6337 <br /> ."r contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class A <br /> A Insurer Midwest Employers Casualty Company Work comp # BNUWC0133392 j <br /> T <br /> 7 ICC Technician's Name Expiration Date <br /> R <br /> ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 07 piping Sump, 91 leek detector, UDC 1/2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> f <br /> P ❑ Approved VApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers NameL. 1 SCJ Date Cis 1G) <br /> Zu <br /> APPLICANT MUST PERFO &61 WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVI ONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN <br /> THE PERFORMANCE OF HE 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 COMPENS TION LA V OF CALIFORNIA." NTRACTOR'S HIRING 0 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFOR ANCE OF HE WORK FOR Wit PER IT IS ISSUE SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." / Q / <br /> Applicant's Sig ;,lure J•ta a / ` ` �• <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 dale below. <br /> NAME Carrie Miller TITLE Office Manager PHONE # (209) 461 -6337 j <br /> ADDRESS 2535 Wigw Dr Stockton , Ca 95205 <br /> SIGNATURE Ll' / G1/ � � DATE 4/22/2022 <br /> i <br /> i <br /> i 206 <br /> i <br /> i <br />