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E NVI RON M TAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK 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 26LD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ABDUL 510-366-9924 <br /> C Facility Name SB GAS & MARKET Phone#2 0 9-8 3 4-8 8 3 8 <br /> I Address515 W. 11TH STREET, TRACY, CA 95376 <br /> L <br /> TCross Street <br /> Y Owner/Operator SANJAY B I RLA Phone# 510-366-9924 <br /> C Contractor Name TOWN & COUNTRY CONTRACTORS, INC. Phone# 916-636-9500 0 <br /> N Contractor Address 3181 LUYUNG DR. STE A CA Lic# 238112 ClassHAZ,A,B, C2 <br /> T <br /> R <br /> A Insurer STATE FUND Work Comp# 3128-2008 <br /> T <br /> T ICC Technician's Certification Number 5 2 5 2 2 7 4-UT Expiration Date 4/14/09 <br /> Q ICC Installer's Certification Number Expiration Date <br /> R 5275557-U1 P 1/10/11 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P E]ApproN ed Approved with conditions ❑Disapproved <br /> L (Sed Attachment With Conditions) <br /> A <br /> N ` (f <br /> 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 OFD} WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 1 I <br /> Applicants Sighature ,' 1 Title Date <br /> $(CLING 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 /> NAMELUCY S I LVAS-THOMAS TITLECONS . SITE COORD PHONE# 916-636-9500 <br /> ADDRESS TOWN & COUNTRY CONTRACTORS, INC. 3181 LUYUNG DRIVE, STE A, RANCHO CORDOVF <br /> CA, 95742 <br /> SIGNATUI <br /> EH230038(revised 12/31/07) <br /> 1 <br />