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S) N { (1 fl ( 1 ( ( I n � Environmental Health Depalfinent <br /> ---- C O U N {T Y -- - - - <br /> f- PPI AGATION rc➢ l!d UNDERGROUND STORAGE. TANK <br /> c1F T woc a OR P PING REPAoR P 1 \\ Rflu <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 # (209461 -6337 Carrie Miller <br /> C Facility Name Quik Stop 148 Phone # (209 ) 369 - 1142 <br /> I Address 205 W. Lockeford St , Lodi CA 95240 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator EG Amercica Phone # ( 508 ) 270-4444 <br /> C Contractor Name Elite IV Contractors Phone # (209461 -6337 <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class A <br /> T <br /> A Insurer Midwest Employers Casualty Company Work comp # BNUWCO133392 <br /> `' <br /> T ICC Technician ' s Name Expiration Date <br /> o ICC Installer' s Name p <br /> R 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 ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name V.4 ^ Date ZZ ?�2:2e <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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS I <br /> OF CALIFORNIA." <br /> O <br /> Applicant's Signature Title ffice Manager Date 6/ 16/2022 <br /> l <br /> BILLING INFORMATION : <br /> I <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 1 <br /> i <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Carrie Miller TITLE Office Manager PHONE # (209) 461 -6337 <br /> i <br /> ADDRESS 2535 Wigwam Dr Stockton CA 95205 <br /> SIGNATURE DATE 6/ 16/2022 <br /> 2of6 <br /> I <br />