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SANJOAQUIN Environmental Health Department <br /> COUNTY -- <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 # ANDREA HOCKENBERRY 916-667-6891 <br /> C Facility Name SINCLAIR/AJ ' S MINI MART Phone # 209-957-2987 <br /> I Address 7906 N EL DORADO STREET, STOCKTON , CA, 95210 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator PAUL TREHAN Phone # 209 -915-6485 <br /> C Contractor Name TANK-TIGHT SYSTEMS , INC Phone # 916-667-6891 <br /> O <br /> N Contractor Address 8515 WATERMAN ROAD , ELK GROVE , CA 95624 CA Lic # 1066914 Class A HAZ <br /> T <br /> R Insurer WESCO INSURANCE COMPANY Work Comp # WWC3507896 <br /> A <br /> C <br /> T ICC Technician 's Name BRIAN ROTH Expiration Date 12/02/2021 <br /> Q <br /> R ICC Installer's Name JAMIE LUCERO Expiration Date 01 /12/2023 <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 87 EAST 10369 GALLONS 87 REGULAR UNKNOWN <br /> A 87 WEST 10369 GALLONS 87 REGULAR UNKNOWN <br /> N <br /> K 87 CENTER 10369 GALLONS 87 REGULAR UNKNOWN <br /> 91 OCT 10369 GALLONS 91 PREMIUM UNKNOWN <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( e Attachm nt With Conditions ) <br /> A ` <br /> N Plan Reviewers Name Date0z 1 <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 Signatur Title OFFICE MANAGER Date 10/28/2021 <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 ANDREA HOCKENBERRY TITLE OFFICE MANAGER PHONE # 916 -667-6891 <br /> ADDRESS 8515 WATERMAN ROAD , ELK GROVE , CA 95624 <br /> SIGNATURE DATE 10/28/2021 <br /> 2of6 <br />