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SANJOAQUIN Environmental Health Department <br /> COUN I 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# Christina Tran 408-213-6039 <br /> A Facility Name <br /> C Y A Gas-Food Mart Phone# 209-707-3191 <br /> I L Address 2115 W Yosemite <br /> _ <br /> I Cross Street <br /> T <br /> Y Owner/Operator Annie Gurpreet Sandhu Phone# 925-785-2000 <br /> c Contractor Name Phone# <br /> O Able Maintenance Inc 707-569 4791 <br /> T Contractor Address 3224 Regional Parkway,Santa Rosa,CA 95403 CA Lic# 312844 Class g A C10 HAZ <br /> R Insurer <br /> A Praetorian Insurance Company Work Comp# 204000064 <br /> C ICC Technician's Name Expiration Date <br /> T See Attached P See Attached <br /> RICC Installers 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 112.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved �,Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name Date—A I 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: "1 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 PERM IS ISSUED,I SHALL E LOY PERSOQIg SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." "Na - C"Vs <br /> Applicant's Signature Title "Y Date <br /> BILLING INFORMATION: r <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 Christina Tran TITLE Project and Permit Coordinator PHONE# 408-213-6039 <br /> ADDRESS 680 Quinn Ave San Jose CA 95112 <br /> SIGNATURE Y&d DATE )I I ZI <br /> 2of6 <br />