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SA N.1 Q A Q U I N Environmental Health Department <br /> OUNi <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 REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Christina Tran 408-213-6039 <br /> C Facility Name Raley's Phone# <br /> I Address 4219 Morada Lane,Stockton,Ca <br /> L <br /> TCross Street <br /> Y Owner/Operator Chittal Shah Phone# 951-313-7490 <br /> C Contractor Name Able Maintenance, Inc Phone# 707-569-4791 <br /> 0 <br /> N Contractor Address CA Lic# <br /> T 3224 Regional Parkway,Santa Rosa,CA 312844 Class gAC10 HAZ <br /> R Insurer Work COMP# <br /> q _Praetorian Ins_uran_ceCom_pany _a _ _ _ 204000064 <br /> T ec same see attached Ex ICC Technician's N (ration Date <br /> T p� <br /> R ICC 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 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S chment With Conditions) <br /> N Plan Reviewers Name' Date ! �b /2 <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 PERMS ISSUEEDD,,ISHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." `i- <br /> Applicant's Signat ret Title � ate 10 31 2&24 <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 signqre.and.date below. <br /> �l to �1 t �3 <br /> NAMEl,1 KK !!2 Ir-Cn TITLE — i"ff l' (�1YI�lUPHONE0 <br /> ADDRESS U) <br /> SIGNATURE / � (�1.'/ DATE <br /> 2 of 6 <br />