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SANJ D AM IN� Environmental Iiewlth Deparirr-rent <br /> 0l..1 Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANG{ <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 REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Carrie Kennard (209)461-6337 <br /> � Facility Name River Point Landing Marina Resort Phone#209-951-4144 <br /> � Address 4950 Buckley Cove Stockton, CA 95219 <br /> Cross Street _ <br /> T <br /> Y Owner/Operator Da-RQy-G {3ert-- zprl—of lips Phone#209-951-0372 <br /> c Contractor Name Elite IV Contractors <br /> 0 Phone#209-461-6337 <br /> T ContractorAddress2535 Wigwam Dr Stockton, Ca 95205 CA Lic# 1001331 Class A <br /> A Insurer Oak River Insurance Company Work comp#ENWC625807 <br /> c T ICC Technician's Name Expiration Date <br /> o 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 1/2,etc.) Installed <br /> T UDC #1/#2 Gasoline & Diesel <br /> A <br /> N -- -- — <br /> K <br /> P pproved with conditions ❑ Disapproved <br /> L (S e Attachment With itions) <br /> A <br /> N Plan Reviewers Name`��-- IF Date <br /> Y� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDAM"TH 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." //�, �vi / <br /> Applicant's Signature_ C � Aae It i Title Office Manager Date 3/9/2026 <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 iDr Stockton, Ca 95205 <br /> SIGNATURE /l� DATE 3/9/2026 <br /> 3of6 <br />