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RECEIVED <br /> MAR 14 2019 Environmental Heaith Department <br /> ' A+OA � ENVIRONMENTAL HEALTH <br /> NTA PERMIT/SERVICES ' <br /> APPLICATION FOR UNDERGROUIF <br /> ND sTgRAGTANK <br /> RETROFIT' OR PIPING REP R PERM <br /> THIS PERMn EXPIRES Iso DAYS FROM TH AL DATE INDICATE mRMrr TYPE 8&OW: <br /> D TANK RETROFIT PIPINt� REPAIWRETRO'FIT UDC RSPAt O IT ❑ COLD_STAftT/1=11IZ UPGRADE <br /> Milli <br /> Proj" Contact &T81.9 no # Tom . Sabed 650-504-7244 <br /> F EPA Site # CAL 000397025 phone # 209-5994261 <br /> A <br /> C Faclifty Namm <br /> Name Gemco Ripon Truck, Plaza_ <br /> I Address 1022 Frontage Rd . Ripon, CA 95366 <br /> L <br /> I Cross Street Brady Lane Phone # 650-58&3088 <br /> T <br /> Y Owner/Operates' R .A.T . Oil , Ina 1045 Airport BNd . South San Francisco; CA 94080 phone # 650 333=5558 <br /> C Contractor Name John Borel Winner Jr. WINNE Class A/Haz <br /> p CA Lic # 824489 <br /> N Contractor Address 1045 Airport Blvd . S . San Francisco. CA 940$0 Work # WKN 166004-1 <br /> T <br /> R Insurer Pe►ferred Employers Insurance Co. RO Box 85476 . San Diego:92 +86 <br /> A Expiration bete 813.1 /19. 9114/19 <br /> C ICC Technician's Name John Winner 5238529/Rob Neimeyer 5248,067 <br /> T Explration , Dats ifI19119 <br /> O ICGlnstallefs Name John Winner: 5238529 1 <br /> R <br /> Tank system work area Tank Size d CF I Installed <br /> OAS piplrq .umR gq �d�bolor, UDC 1112t .06L) <br /> system 12j=gal 87 Octane Unleaded gasoline <br /> IF T 87 pipingy. . 8 ,OOOgaf 91 octane Unleaded gesso!"ins <br /> A 91 pipingsystem <br /> NIF <br /> K <br /> f APpwvs vAth axWitions El Disapproved . <br /> P ❑ ApproVed L L ment With.Conditions) <br /> A Date 0 �1 9 al %IF — <br /> N pian Reviewers Name <br /> yy1TH 8AN ;IOAQUIN COUNTY QRDINS� STATE LAW8, AND RULE8 AND REGULATIONS OF SAN <br /> CANT MUST PERFOW ALL DEPAR?i►�. OWNER OR . LICENSF.D A(;ENi 3 610NATt1R1 .E CERrIF►E3 "RiE CLI CQ To s "I ME, SU TFa TO <br /> OJWUIN COUTRI', EhIVIRON1ITlU- H __ <br /> PERFoi3MAryr OF THE WORK FOR YrIiIGH THIS PERNAT"IS 13SUED, l SFW.L NOT EMPLOY At+1Y PERSON 1N SUCH A MANNER f4S TO BECOME ON LAWS <br /> yy«, 113 CQMPEN8ATION o CAVF. FORV�YNICH�TI IITRT ts'�mSSINGJED, t sFWl ENsh-o PE BRSON�s S)BJECfiRW�ORKER'gCOMR NO: "I CE17nF1f <br /> T THE <br /> IN THEIF <br /> E <br /> OF. CALIFORNW V , Contractor 2128119 <br /> Title Da>e <br /> ss <br /> BILLING INFORMATION: <br /> to be billefor EFiD staff time expended �yond permit prayn1em coverege. Per <br /> Indkste the rdor add <br /> esponsible party .� dlftent thsh . e.g. property -owner, the Vii; must <br /> tank. N the pEutY desl9n <br /> adnowiedge this Iesponsibillty for the baling by signature and date below. <br /> 564 � ?r i T11 ®W N e, K. PHONE #. 650 8&3088 <br /> NAME �oM <br /> ADLIRESS . 1045 Airport Blvd . South San Francisco, CA 94080 <br /> 1 IF <br /> DATE <br /> IF <br /> � I 1tll � <br /> $1C3NATU . . <br /> 2016 <br />