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SANJOAQUIN Environmental Health Department <br /> COUNTY -- <br /> APPLICATION <br /> OUNTY -- <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 BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # TONY MEHROKE 916 -667-6891 <br /> C Facility Name A & A GAS & FOOD MART Phone # 209-825 -0332 <br /> L <br /> Address 1330 EAST YOSEMITE AVENUE , MANTECA , CA 95336 <br /> I Cross Street <br /> T <br /> Y Owner/Operator GHULAM ALI Phone # <br /> C Contractor Name TANK-TIGHT SYSTEMS , INC . Phone # 916-667 -6891 <br /> 0 <br /> N Contractor Address 8515 WATERMAN ROAD , ELK GROVE , CA 95624 CA Lic # 1066914 Class A HAZ <br /> T <br /> R <br /> A Insurer WESCO INSURANCE COMPANY Work Comp # WWC3507896 <br /> C <br /> T ICC Technician 's Name BRIAN ROTH Expiration Date 12/14/2021 <br /> 0 <br /> R ICC Installer's Name JAMES DAY Expiration Date 11 /4/2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T UNDERGROUND 1 OK SPLIT 91 <br /> A UNDERGROUND 10K SPLIT DIESEL <br /> N <br /> K UNDERGROUND 20K 87 <br /> P ❑ Approved \ © Approved with conditions ❑ Disapproved <br /> L \ (See Attachment With Conditions) <br /> A M \\1 f <br /> N Plan Reviewers Name ` 1� Date l �% I2C, 2 <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 : "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 C) Title TitlePRESIDENT/OWNER Date 09/16/2021 <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 KULVIR (TONY) MEHROKE TITLE PRESIDENT/OWNER PHONE # 916-667-6891 <br /> ADDRESS 8515 WATERMAN ROAD , ELK GROVE , CA 95624 <br /> SIGNATURE D V \ ����� DATE 09/24/2021 <br /> 2 of 6 <br />