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SA N JOAQUIN I_ 11Vit01 , ltu+ still I ir ;rlih flcl ! :ni, r+ r . � if . <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 160 DAYS FROM TI IE APPROVAL DMF . INDICATE PMI TYPO: BELOW <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site # C. ft ft. 0 O p Z t_ I 13 Project contact & Telephone #_Carrie Miller ( 209) 46. 1 -6337 _. <br /> A <br /> Facility Name Loves Travel Center 0538 Phony tt (209 ) 333-9392 <br /> I _. <br /> L Address 15250 N , Thornton Road Lodi Ca 95242 <br /> 1 Cross Street <br /> Y Owner/Operator Jess Diaz Phone # (405) 6137- 1060 <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 <br /> Rinsurer Midwest Employers Casualty Company Co Work comp # 8NUWC0133392 <br /> A <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer' s Name Expiration Dale <br /> Tank system work area Tank Size Chemicals Stored Currently Dale UST <br /> {i6, e7 piping rump, 91 leak delCaa. UDC 1/Z, etc.) Installed <br /> T j <br /> A I <br /> N <br /> K <br /> 11 Wool <br /> RI <br /> P �] Approved pproved with conditions ❑ Disapproved <br /> L <br /> (See Attachment With Conditions) <br /> A Q <br /> N a� l <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY , ENVIRO MENTAL. HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING 01 CERTIFY THAT IN <br /> THE PERFORMANCE OF E 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 cOMPENSCALIFORNIA-04 A ON LAWS OF CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFOR ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA," f !�� <br /> Applicant's Slpnature ' G T,,Ia Office Manager D�,o 4/3/2023 RON <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 . /t <br /> S Ct: j ! c. TITLE Irl, �1 hh SC' J L . PHONE it � �a �? ' r0 <br /> NAME fj C <br /> l <br /> ADDRESS C I <br /> SIGNATURE - DATE <br /> 2ofe - <br />