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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 /> IXTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> C Facility Name Super Stop Gas & Liquor Phone # (209 ) 239-4475 <br /> L Address 290 N . Main St . <br /> T Cross Street E . North St. <br /> Y owner/operator Mandeep Dua Phone # ( 209) 239-4475 <br /> 0 Contractor Name LC Services Phone # (559) 444- 1730 <br /> 0 <br /> T Contractor Address 3887 N Valentine Ave CA Lic # 779267 Class A, B C10 , C21 , Ha <br /> A Insurer Ace American Work Comp # C69980430 <br /> T ICC Technician's Name Cliffton Woods Expiration Date 8/30/2024 <br /> R ICC Installer's Name Cliffton Woods Expiration Date 8/30/2024 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i .e. 87 plping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T 87 Drop Tube Replacement Gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved VApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A I <br /> N Plan Reviewers Name y V Date O ! ZU L L <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 l ^-� ��- Title Project Coordinator Date 9/ 13/2022 <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 James Otto TITLE Project Coordinator PHONE # 559-444- 1730 <br /> ADDRESS 3887 N Valentine Ave . Fresno , CA 93722 <br /> SIGNATURE James Otto DATE 9/6/2022 <br /> 2of6 <br />