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SANJOAQUIN Environmental Health Department <br /> -- C O U N T Y ----- <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 # <br /> Facility Name SUPER STOP GAS & LIQUOR Phone # 209 815-5180 <br /> I <br /> L Address 290 N MAIN STREET SUITE C <br /> I Cross Street E . NORTH STREET <br /> T <br /> Y Owner/Operator MANDEEP DUA Phone # 209 815 -5180 <br /> c Contractor Name TANK-TIGHT SYSTEMS , INC Phone # 916 667 -6891 <br /> O <br /> NCA 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 12/2/2021 <br /> Q <br /> R ICC Installer's Name JAMIE LUCERO Expiration Date 1 /12/2023 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved V Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A i d <br /> N Plan Reviewers Name l YV Date 0 Z 1 7� 0 Ll <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 �� " `� v Title CEO Date 10/22/2021 <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 TONY MEHROKE TITLE CEO PHONE # 916 667-6891 <br /> ADDRESS 8515 WATERMAN `ROAD , ELK GROVE , CA 95624 <br /> SIGNATURE C) v ���d ` DATE 10/22/2021 <br /> 2 of 6 <br />