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RECEIVED <br /> SA N,4 Q A O U I N MAR 14 2019 Environmental Health Department <br /> COUNTY E"RoNMENTAL HEALTH <br /> PERMIRSERWCES <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXNRES 180 DAYS FROM TN AL DATE MNNCJITE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT gtPIPING REPAIR/RETROFIT XuDcREPAIRmmom ❑COLD START/EVR UPGRADE <br /> F EPA Sibs# CAL000397025 Project Contact&Telephone# Tom Saberi 650-5047244 <br /> A <br /> c Facility Name Gemco Ripon Truck Plaza Phone# 209-5994261 <br /> I <br /> L Address 1022 Frontage Rd. Ripon, CA 95366 <br /> Tb Cross Sbet Brady Lane <br /> Y Owner/Operator R.A.T.Oil, Inc. 1045 Airport Blvd.South San Francisco,CA 94080 Fhons# 650-588-3088 <br /> Contractor Name John Borel Winner Jr. <br /> 0 Phone# 650-333-5558 <br /> N COrAMCtor Address 1045 Airport Blvd.S.San Francisco. CA 94080 CA UC# 824489 Class A/Haz <br /> T <br /> A Insurer Perferred Employers Insurance Co. PO Box 85478 San Diego 92186 Worts COMP# WKN 166004-1 <br /> T ICC Technidan's Name John Winner 5238529/Rob Neimeyer 5248067 ExpatatlOn Date 8/31/19.9/14/19 <br /> O <br /> R ICC Installer's Name John Winner 5238529 Expiration Date 10/9/19 <br /> Tank system work area Tank Size Chemicals Stored Curreriby Date UST <br /> OA.57 plprp w ,01)w* UDC 112.st.) Installed <br /> T 87 piping system 12,000gal 87 Octane Unleaded gasoline <br /> A 91 piping system 8,000gal 91 Octane Unleaded gasoline <br /> N <br /> K <br /> P ❑ Approved Approved with coition ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name: Date <br /> AppucANT MUST PERFORM ALL WO C Ape6RIbANm WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> COMMJOAQUIN ENVIRONMENTAL HtRM DEPARTMENT.OWNER OR LICID D AGENTS SKM"TURE CEIMFIES THE FOLLOWING. 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,:1 SWILL NOT EMPLOY ANY PER80N IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTORS HIM OR SUBCONTRACTING 8KAIATURE CERTIFIES THE FOLLOIMNO: "1 CERTIFY <br /> T IN THE PERFORMANCE OF THE WOFf FOR NMICH THIS PERMIT IS ISSUED,I MAU EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> CALIFORNIA.*OF <br /> s g s v T& Contractor Dsft 2/28/19 <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 dlf ww t than the pem* appkart, e.g. property owner, the party must <br /> admowledge this responsibility for the billing by signature and date below. <br /> NAME TITLE u PHONE# 650-588-3088 <br /> ADDRESS 1045 Airport Blvd.South San Francisco, CA 94080 SQ�er �b� .L.h <br /> SIGNATURE DATE <br /> 2 of 6 <br />