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AMENDMENT (2) 6/10/2021 34243 Chrisman Rd Tracy, CA 95304 <br /> SAN JOAQUIN SR0083263 Environmental Ftealth Department <br /> CC)UN"TY <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 /> 0 TANK RETROFIT N PIPING REPAIR/RETROFIT 0j UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Deborah Jones (209) 461-6337 <br /> C Facility Name Country Mart Gas & Food Phone#(209) 914-5583 <br /> I Address 34243 Chrisman Road Tracy, CA 95304 <br /> TCross Street <br /> Y Owner/Operator Sand u Singh Phone#(209) 914-5583 <br /> c Contractor Name Deborah Jones Phone#(209) 461-6337 <br /> T Contractor Address 2535 Wigwam Drive Stockton, CA 95205 CA Lic# 1001331 Class A-Hazmat <br /> A Insurer Midwest Employees Casualty Company Work comp#BNUWC0133392 <br /> TICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved l"1 Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date jU_I U <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 /> 4tg4ak <br /> Applicant's Signature (M!�2Title Administrative Assistant Date 6/08/2021 <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 Deborah Jones TITLE Administrative Assistant PHONE# (209)461-6337 <br /> ADDRESS 2535 Wigwam Drive Stockton, CA 95205 <br /> SIGNATURE DATE 06/08/2021 <br /> 2of6 <br />