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ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` SAN JOAQUIN COUNTY <br /> t . <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone ; (209) 468" 3420 Fax: (209 ) 468-3433 <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 9ELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROMT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Silg # Project Contact & Telephone # Emll Crain 916 -371 -2380 <br /> C Facility Name A&A Gas and Food 777Phone # 510-396-5560 <br /> � Address 1330 E Yosemite Ave, Manteca , CA <br /> TCross Street <br /> Y OwnerlOperatorGhulamAll Phone # 510-.396-5560 <br /> C Contractor Name BZ Maintenance Phone # <br /> T Contractor Address PO Box 933, West Sacramento , CA 95691 CA Lie # Class <br /> A Insurer see attached Work comp # <br /> T ICC Technician's Name see attached Expiration Date <br /> R ICC Installers Name Expiration -Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le s7 riprg eunp of leak eeteda, uoC 12 ELM) Installed <br /> T <br /> N <br /> K L , <br /> F, ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name o 1� t Dale ( .2 0 2c) <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: 9 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHIG PERMIT IS ISSUED, I SHALL EMPLOY PER ONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> pprcanl'sSlgnature Title yC Dete <br /> ( , BILLING INFORMATION . <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank, it <br /> the party designated below is different than the permit applicant, e ,g , property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Ghulam Ali Owner 510-396-5560 <br /> TITLE PHONE # <br /> ADDRESS 1330 E Yosemite Ave , Manteca , Ca 95336 <br /> SIGNATURE <br /> DATE <br /> EH230038 (revised 12- 11 -15) 2 <br />