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SANLJ o Q Q U IN Environmental iealth Department <br /> COUNTRY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RFT' R® FIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ 'TANK RETROFIT ❑ PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Deborah Jones ( 209 ) 461 -6337 <br /> A <br /> C Facility Name ahant Food & Fuel Stop , Inc . Phone # 209 32L2836 <br /> I Address <br /> L 24323 E Highway 99 Acampo , CA 95220 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator nqh Phone # 209 327-2836 <br /> o Contractor Name Phone #Deborah Jones 209461M37 <br /> T Contractor Address 535 W10warn Drive CA Lic # 1001331 Class LHazrnat <br /> A Insurer Midwest Employers Casualty Company Work comp # BNUW 0133392 <br /> T ICC Technician 's Name Michal Kennard Expiration Date 6/ 19/2021 <br /> R ICC Installer's Name Mchal KennardExpiration Date 6/ 19/2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 07 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ee t achment With Conditions ) <br /> A i /C;v <br /> N Plan Reviewers Name 4 ' ' Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE ITH 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 : N 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 /> jp <br /> Applicant's Signal Title Administrative Assistant Date 3 / 18/2021 <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 /> SIGNATUR DATE 3/ 18/2021 <br /> 2of6 <br />