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SAN JOAQUIN <br /> aaQUIN Environmental Health Department - <br /> APPLICATIONFOR 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 # Carrie Miller (209) 461 -6337 <br /> � Facility Name California Stop Phone # (209 ) 462 -7621 <br /> I Address <br /> L 2224 Manthey Rd Stockton , CA 95206 <br /> TCross Street <br /> Y Owner/Operator Thien Phan Phone # (209) 406- 1484 <br /> c Contractor Name Elite IV Contractors Phone # (209 ) 461 -6337 <br /> T Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic #1001331 Class A <br /> A Insurer Midwest Employers Casualty Company Co Work Comp # BNUWC0133392 <br /> TICC Technician' s Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDC 1/2, etc. ) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A / �, <br /> N Plan Reviewers Name l� P � Date 10G <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 �� Office ffice Manager <br /> Dale 6/ 13/2023 <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 D^r�,, Stockton , Ca 95205 <br /> SIGNATURE r � r� DATE 6/ 1312023 <br /> 2of6 <br />