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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY RECEIVE® 1868 E. Hazelton Ave., Stockton, California 95205 Telephone: (209) 468-3420 Fax: (209) 468-3433 DEC 2 3 2017 APPLICATION FOR UNDERGROUND STORAGE TALWIRONMENTAL HEALTH RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT []UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE F EPA Site # Project Contact & Telephone # Nick Patel (510) 677-4467 A C Facility Name ARP Mini Mart Phone # (209/835-7777 1 L Address 25775 Patterson Pass Road, Tracy, CA 95377 I Cross Street Interstate 580 T Y Owner/OperatorHarshad Patel Phohe #(510) 600-3360 C 0 Contractor Name Fuel systems consulting Phone # (510) 677-4467 N T Contractor Address P O Box 1059, Rio Vista CA LicP/741522 Class Haz A, C61 -D40 R A Insurer State Compensation Insurance Fund Work Comp #9208751 T ICC Technician's Name Herbert Pease 7 Expiration Date 11/29/2018 R ICC Installer's Name Herbert Pease �' Expiration Date 11/29/2018 Tank system work area Tank Size Chemicals Stored Currently Date UST (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed T UDC 3-4 NA i NA NA A UDC 7-8 NA NA NA N K Tank 1 10,00q ? Regular Gasoline 1/1/1994 P ❑ Approved ❑ Approved with conditions ❑ Disapproved L (See Attachment With Conditions) A N Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." Nick Patel 12/26/2017 Applicant's Signature Title Date BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME Nick Patel TITLE Project Co-ordinator, ARP minimart PHONE # 510-677-4467 ADDRESS 25775 Patterson Pass Road, Tracy, CA SIGNA EH230038 (revised 7-26-2016) 2 DATE 12/26/2017