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SAN.-; 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# Christina Tran 408-213-6039 � <br /> C Facility Name Quik Stop Market 121 Phone# 209-239-2957 <br /> � Address 1196 Louise Ave Manteca CA 95336 <br /> 1 Cross Street <br /> T - — -- <br /> Y Owner/Operator Quik Stop C?O Jessica Pfeffer Phone# 508-270-4444 <br /> o Contractor NameService 3ati Phone# 408-971-2445 <br /> T Contractor Address 680QuinnSJ CA 95112 CA Lie# 485184 Class BC61/D40 <br /> A Insurer see attached Work Comp # HAZ <br /> TICC Technician's Name Expiration Date <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,81 leek detector.UDC 112,etc.) Installed <br /> T <br /> A <br /> N -- <br /> K NJO CHANGE <br /> P Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name _a&T. y tti Date 2�5 <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 PERMIT IS ISSUED, I LL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 1 <br /> Applicant's Signature 1 Tide — Date <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 Christina Tran TITLE Permit/Project Coordinator PHONE# 4()R-913-R039 <br /> ADDRESS 680 Quinn Ave, San Jose, Ca 95112 <br /> J tz <br /> SIGNATURE ?' / DATE <br /> 3of6 <br />