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WOONEnvironmental Health Department <br /> C S t_) I` 41 Y . . . _. . RECEIVED <br /> APPLICATION FOR UNDERGROUND STORAGE TANK APR 10 2024 <br /> RETROFIT OR PIPING PAI PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BErcL���� HEALTH <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD �'A ICES <br /> F EPA Site # Project Contact & Telephone # (209) 461 -6337 <br /> C Facility Name West Valley Auto Service Phone # (209) 836-3466 <br /> I <br /> L Address 2615 W. Grant Line Rd Tracy <br /> I Cross Street <br /> TPhone # (415) 572 -4837 <br /> Y Owner/OperatorVikas Patel <br /> o Contractor Name Elite IV Contractors Phone # <br /> T Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic # 1001331 Class A <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> cICC Technician' s Name Expiration Date <br /> T <br /> R ICC 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 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved rJ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name i� � Date _D4 2 ej hDa <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 C4: Title Office Manager Date 4/ 10/2024 <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 -6342 <br /> ADDRESS 2535 Wigwam Dr Stockton , Ca 95205 <br /> SIGNATURE C� /"'"&4DATE4/10/2024 <br /> " <br /> 2of6 <br />