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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton Ave., Stockton, California 95205 Telephone: (209) 468-3420 Fax: (209) 468-3433 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT R1, - - " '' - ` I �V`- � D E,-- U L;A.� L JUN 0 8 2017 ENVIRONMENTAL HEALTH THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: -- 'OE T ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ✓❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE , i V 1 F EPA Site # Project Contact & Telephone # Nick Patel (510) 477-4467 A C Facility Name ARP Mini Mart Phone #(209) 835-7777 1 L Address 25775 Patterson Pass Road, Tracy, CA 95377 TCross Street Interstate 580 Y Owner/Operator Harshad Patel Phone # (510) 600-3360 C Q Contractor Name Confidence UST Services, Inc. Phone # (661) 631-3870 N T Contractor Address 16250 Meacham Road, Bakersfield, CA 93314 CA Lic # 804904 Class Haz A, C61 -D40 AInsurer State Insurance Fund Work Comp # 1308371-2016 TICC Technician's Name Frank Landa Expiration Date 01/25/2019 R ICC Installer's Name Frank Landa Expiration Date 10/19/2017 Tank system work area Tank Size Chemicals Stored Currently Date UST (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed T UDC 1-2 NA NA NA A UDC 3-4 NA NA NA N K UDC 5-6 NA NA NA UDC 7-8 NA NA NA P ❑ Approved ❑ Approved with conditions ❑ Disapproved L (See Attachment With Conditions) A N Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." Karli Karns 06/07/2017 Applicant's Signature Title Date BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME Karli Karns TITLE Dispatch Coord., Confidence UST PHONE # 661-631-3870 ADDRESS 16250 Meacham Road, Bakersfield, CA 93314 06/07/2017 SIGNA EH230038 (revised 7-26-2016) 2