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ENVIRONMENTAL HEALTH DEPAFT K,�Tn F <br /> SAN JOAQUIN COUNTY , <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 01 ' <br /> APPLICATION FOR UNDERGROUND STORAGE TANINVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FRCM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT []PIPING REPAIR/RETROFIT QUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# CAL Ooa ?— 2'7 3 Q Project Contact&Telephone#Nick Patel(510)677-4467 <br /> A <br /> C Facility Name ARP Mini Mart Phone#(209)835-7777 <br /> 1 Address 25775 Patterson Pass Road,Tracy,CA 95377 <br /> L <br /> I Cross Street Interstate 580 <br /> T — <br /> Y Owner/Operator Harshad Patel Phone#(510)600-3360 <br /> C Contractor Name Fuel systems consulting Phone#(510)677-4467 <br /> 0 <br /> N <br /> T Contractor Address P O Box 1059,Rio Vista CA Lic# 741522 Class Haz A,C61-D40 <br /> R <br /> A Insurer State Compensation Insurance Fund Work Comp#9208751 <br /> T ICC Technician's Name Herbert Pease Expiration Date 11/29/2018 <br /> R ICC Installet's Name Herbert Pease Expiration Date 11/29/2018 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T UDC 3-4 NA NA NA <br /> A UDC 7-8 NA NA NA <br /> N <br /> K Tank 1 10,000 Regular Gasoline 1/1/1994 <br /> P ❑ Approved A proved with conditions ❑ Disapproved <br /> L See A a hment 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN <br /> HE 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: 1 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 Title Nick Patel Date 12126/2017 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Nick Patel TITLE Project Co-ordinator,ARP minimart PHONE#510-677-4467 <br /> ADDRESS 25775 Patterson Pass Road,Tracy,CA <br /> SIGNATURE DATE 12/26/2017 <br /> EH230038(revised 7-26-2016) 2 <br />