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SAN , JDAU IN Environmental Health Department <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 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD STARTIEVIR UPGRADE <br /> F EPA Site#0003824G I Project Contact&Telephone#Carrie Miller(209)461-6337 <br /> A <br /> C Facility NameTulare Farms Phone#209-235-3055 <br /> I Address 2771 French Camp Manteca, CA 95336 <br /> L <br /> T I Cross Street <br /> y peratorJann Jansen Phone#209-482-6663 <br /> C Contractor Name Elite IV Contractors Phone#209-461-6337 <br /> 0 <br /> N <br /> T Contractor Address 2535 Wigwam Dr Stockton, Ca 95205 CA Lic# 1001331 Class A <br /> R <br /> A insurer StarNet Insurance Company Work Comp#BNUWC01 33392 <br /> C <br /> T ICC Technician's Name Expiration Date <br /> ' I [CC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (.e.87 piping sump,91 leak detector,UDC 1/2.etc.) Installed <br /> T Unleaecled UST 6,000 gallons Unleaded Gasoline <br /> A <br /> N <br /> K <br /> P El Approved Approved with conditions El Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name— 011110-w/ A"4,1411r.4y 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 Ca44Z�, 71k&4, Title Office Manager Date 3/18/2025 <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, Cal 95205 <br /> SIGNATURE_ C� DATE 3/18/2025 <br /> 2 of 6 <br />