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SANJOAQUIN Environmental Health Department <br /> C 0 U Nf T Y-_-___ <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 ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> 1= EPA Site# I Project Contact&Telephone#Carrie Miller(209) 461-6337 <br /> A <br /> C Facility Name Top Gas Phone# ) u cf. <br /> � Address 2057 S. El Dorado Stockton, Ca 95206 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Hakimullah Wafa Phone#916-812-8984 <br /> o Contractor Name Elite IV Contractors Phone#(209) 461-6337 <br /> T Contractor Address 2535 Wigwam Dr Stockton, Ca 95205 CA Lic# Class <br /> A InsurerOak River Insurance Company Work comp#ENWC625807 <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 /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T 87 STP <br /> A <br /> N <br /> K <br /> P X Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Stacy Rivera Date 4/3/26 <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 /1�41e' Title Office Manager Date 2/18/2026 <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 Dori Stockton, Ca 95205 <br /> SIGNATURE DATE <br /> 3of6 <br />