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SANJOAQUIN Environmental Health Department <br /> - <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 STARTIEVR UPGRADE <br /> F EPA Site # CAL000448151 Project Contact & Telephone # Mushtaq Omar ( 510 ) 432 -5211 <br /> A <br /> C Facility Name SB Gas and Market Phone # (209 ) 834-8838 <br /> � Address 515 W 11th St Tracy , CA 95376 <br /> TCross Street Bessie Ave . <br /> Y Owner/Operator Mushtaq Omar Phone # ( 510) 432 -5211 <br /> C Contractor Name Tank Tight systems , Inc . Phone # ( 916 ) 3784168 <br /> O <br /> N <br /> T Contractor Address 8515 Waterman Rd Elk Grove , CA 95624 CA Lic # 1066914 Class A HAZ <br /> A Insurer Wesco Insurance Company Work Comp # WWC3507896 <br /> T ICC Technician ' s Name Brian Roth Sr . Expiration Date 11 /15/2023 <br /> R ICC Installer' s Name Manpreet Arman Expiration Date 02/27/2025 <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 UNDERGROUND 12K Unleaded Regular <br /> A UNDERGROUND 6K/6K Unleaded Supreme/Diesel <br /> N <br /> K <br /> P ❑ Approved d Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name a"'�o\ 1vsU Date ©"I 114 171)Z3 <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 Title Owner Date 07/ 10/2023 <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 Mustaq Omar TITLE OWNER/CEO PHONE # ( 510 ) 432 -5211 <br /> ADDRESS P . O . Box Exeter CA 93221 <br /> SIGNATURE - DATE 07/ 10/2023 <br /> 2 of 6 <br />