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( n N A A Q U I N Environmental Health Department <br /> . . _ C- CWNTY . . . . . <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <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 # <br /> CFacility Name Ripon CFN Phone # Carrie Miller (209) 461 =6337 <br /> I Address 816 S . Frontage RD Ripon , CA 95366 <br /> L <br /> TCross Street <br /> Y Owner/OperatorVandePol Petroleum Phone # (209) 465-3421 <br /> C Contractor Name Elite IV Contractors Phone # <br /> 0 <br /> N Contractor Address CA Lic # 1001331 Class A <br /> T <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> T ICC Technician' s Name Expiration Date <br /> T <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 ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N 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, 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 <br /> OF CALIFORNIA." <br /> Applicant's Signature Ca4AZ4 WMATitle Office Manager Date 3/6/2023 <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 2535 Wigwam Dr Stockton , Ca 95205 <br /> SIGNATURE DATE 3/6/2023 <br /> 2 of 6 <br />