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SAN JOAQUIN Environmental Health Department <br /> - COU NTY - - <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 /> � <br /> Facility Name Super Stop Phone # 209 -239 -4475 <br /> I <br /> L Address 290 N Main St . Manteca , CA 95336 <br /> T Cross Street E North St <br /> Y Owner/Operator Mandeep Singh Dua Phone # <br /> C Contractor Name LC Services Phone # 559444- 1730 <br /> O <br /> N <br /> T Contractor Address 3887 N Valentine Ave CA Lic # 779267 Class A, B , C10 , C21 Ha <br /> R Insurer Ace American Insurance Company Work Comp # C55561394 <br /> TICC Technician ' s Name Expiration Date <br /> RICC Installer's Name Expiration Date <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 All (4 ) Dispenser UDCs <br /> A <br /> N <br /> K <br /> P ❑ Approved i I/Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> N Plan Reviewers Name/ /� Date_ _ � �� oZ� <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." / �+f <br /> Applicant's Signature alrtl.?%Y o Title Project Coordinator Date 1 /30/2024 <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 # 559444- 1730 <br /> ADDRESS 3887 N Valentine Ave . Fresno , CA 93722 <br /> SIGNATURE 2aoor 4i V t ro DATE 1 /30/2024 <br /> 2 of 6 <br />