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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 # Scott Willett / 760 277 -2117 <br /> A Facility Name Phone # 760 722 - 9002 <br /> IS y Anabi Oil - Shell ( ) <br /> I Address 3725 N Tracy Blvd , Tracy , CA <br /> T Cross Street W . Larch Rd . <br /> Y Owner/Operator Anabi Oil / Chittal Shah Phone # ( 951 ) 313 - 7490 <br /> o Contractor Name DiMaggio Maintenance , Inc . c/o Scott Willett Phone # ( 760 ) 722 - 9002 <br /> TN Contractor Address 1040 Joshua Way , Vista , CA 92081 CA Lic # 888681 ClassA , B , C- 10 , Haz <br /> A Insurer Insurance Com an of the West work Comp # WSD503573005 <br /> T ICC Technician' s Name Matt DIMa 10 Expiration Date03/09/2025 <br /> 0ICC Installer' s Name Matt DiMa to Expiration Date 03 /29/2025 <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 <br /> N R& R existing Penetration Unleaded <br /> K Fittings in all UST Fill Sumps . Mid - Grade <br /> Premium <br /> Diesel <br /> P ❑ Approved Ind Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> LfA <br /> N Plan Reviewers Name � ' � �% Date () '� I0 �7 Lo Z <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 Operations Manager Date 12 /06/23 <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 DiMaggio Maintenance , Inc . TITLE Operations Manager PHONE #(760 ) 277 - 2117 <br /> c/o Scott Willett <br /> ADDRESS 1/040 Joshua Way , Vista , CA 92081 <br /> SIGNATURE ' ` DATE 12 /06/23 <br /> 2 of 6 <br />