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SAN-JOAQUIN Environmental Health Department <br /> . COUNTY,..___ <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 /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Carrie Kennard209-461-6337 <br /> C Facility Name Arco Station #83560 Phone# <br /> � Address2908 W. Bejamin Holt Dr. Stockton, Ca 95207 <br /> 1 Cross Street <br /> Y Owner/Operator Lawrence Wight Phone#209-993-7825 <br /> o Contractor Wigwam Dr Stockton, Ca 95205 Phone#209-461-6337 <br /> T Contractor Address2535 Wigwam Dr Stockton, Ca 95205 CALic#1001331 Class A <br /> A InsurerOak River Insurance Company Work Comp#ENWC625807 <br /> TICC Technician's Name Expiration Date <br /> o ]CC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) y Installed <br /> T 87 Siphon Tank 12,000 gal Regular Unleaded 4/1/1999 <br /> A All UDC's <br /> N <br /> K Transition Sump <br /> P ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <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." �j��,��� <br /> Applicant's Signature ` a' Title Office Manager Date 12/10/2025 <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, Ca 95205 <br /> SIGNATURE � Aaoz DATE 12/10/2025 <br /> 3of6 <br /> I <br />