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SAN JOAQUIN EnvironmentPt) <br /> a�tl� ,f7epartm �n /P <br /> - - COUNTY - <br /> APPLICATION <br /> - COUNTY - - {�+ ILM <br /> / Lj <br /> APPLICATION FOR UNDERGROUND STORAGE TANK JUI- 01 2020 <br /> RETROFIT OR PIPING REPAIR PERMIT (� IRON <br /> �t <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE B�CO1YIRO �IMENTAL HEALTH <br /> 11 <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRAb ENT <br /> F EPA Site # Project Contact & Telephone # Scott Willett / 760 722 - 9002 <br /> � Facility Name Anabi Oil - Shell Phone # ( 760 ) 722 - 9002 <br /> L <br /> Address 3725 N . Trac Boulevard , Tracy , CA 95304 <br /> I Cross Street West Larch Road <br /> T <br /> Y owner/Operator Anabi Oil / Chittal Shah Phone # ( 951 ) 313 - 7490 <br /> o Contractor Name DiMaggio Maintenance , Inc . c/o Scott Willett Phone # ( 760 ) 722 - 9002 <br /> N Contractor Address 2603 Industry St . , Oceanside , CA 920541 CA Lic # 888681 Class A , B , Haz <br /> A Insurer Insurance Company of the West work Comp # WSD503573000 <br /> T ICC Technician ' s Name Matt DiMaggio Expiration Date03/09/2021 <br /> ° ICC Installer's Name Matt DiMaggio Expiration Date 03/29/2021 <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 <br /> N Remove Existing Fuel Unleaded <br /> K Dispensers , Replace with new Mid - Grade <br /> Fuel Dispensers . Premium <br /> Diesel <br /> P ❑ App%ove) proved with conditions ❑ Disapproved <br /> L hment With Conditions) <br /> A3 42,07, 0 <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WOR 1 OR E WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY , ENVIRONMENTAL H H 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 T Title Operations Manager Date 03/05/2020 <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 DiMaggio Maintenance , Inc . TITLE Operations Manager PHONE # ( 760 ) 722 - 9002 <br /> c/o Scott Willett <br /> ADDRESS 2�J603 Industry Street Oceanside , CA 92054 <br /> SIGNATURE ' t DATE 03/05/2020 <br /> 2of6 <br />