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SA N JOAQUIN 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# <br /> A <br /> Facility Name Quik Stop Market 121 Phone# <br /> � Address 1196 W Louise Ave Manteca CA 95336 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Quik Stop Markets Phone# <br /> o Contractor Name Service Station Sy stems Phone# 916-343-3857 <br /> N Contractor Address 3900 Commerce Drive West Sacramento, CA 95691 CA Lic# 485184 Class B, C61/D40, HAZ <br /> T <br /> R Insurer Work Comp# <br /> A INSURANCE COMPANY OF THE WEST p WLV507821801 <br /> TICC Technician's Name Expiration Date <br /> R ICC Installer's Name Michael Raymond Expiration Date 03/24/27 <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 No Changes <br /> A <br /> N <br /> K <br /> P Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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 $ CGL6b`�b, Title Operations Manager Date 08/25/25 <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 Stephanie Charissa TITLE Operations Manager PHONE# 916-343-3857 <br /> ADDRESS 3900 Commerce Drive West Sacramento, CA 95691 <br /> SIGNATURE ,SHAh4 i4-(.f'G"i4,w DATE 08/25/25 <br /> 3 of 6 <br />