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SAN JOAQUIN Environmental Health Department <br /> -- COUNTY JUN `4 X020 <br /> APPLICATION FOR UNDERGROUND STORAGE, TAN ,K <br /> ONMENTAL I EALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPART ��( FNT <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 # Scott Willett / 760 722 - 9002 <br /> � <br /> Facility Name Anabi Oil - Shell Phone # ( 760 ) 722 - 9002 <br /> I Address 2375 West Grant Line Road , Tracy , CA 95377 <br /> L <br /> I Cross Street Joe Pombo Parkway <br /> T <br /> Y Owner/Operator Anabi Oil / Chittal Shah Phone # ( 951 ) 313 - 7490 <br /> c Contractor Name DiMaggio Maintenance , Inc . c/o Scott Willett Phone # ( 760 ) 722 - 9002 <br /> T Contractor Address 2603 Indust St . , Oceanside , CA 92054 CA Lic # 888681 Class A , B , Haz <br /> A Insurer Insurance Company of the West work Comp # WSD503573000 <br /> T ICC Technician 's Name Matt DiMaggio Expiration Date03/09/2021 <br /> R ICC Installer's Name Matt DiMaggio Expiration Date 03/29/2021 <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 <br /> N Remove Existing Fuel Unleaded <br /> K Dispensers , Replace with new Mid - Grade <br /> Fuel Dispensers . Premium <br /> Diesel <br /> P ❑ Approved proved with conditions Ll Disapproved <br /> L j (S e Attach nt With Conditions) <br /> N Plan Reviewers Name DateI I ZO <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: 111 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 Operations Manager Date 03/05/2020 <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 DiMaggio Maintenance , Inc . TITLE Operations Manager PHONE # ( 760 ) 722 - 9002 <br /> c/o Scott Willett <br /> ADDRESS 2�J603 Indust !)( Street Oceanside CA 92054 <br /> SIGNATURE , 1 DATE 03/05/2020 <br /> 2of6 <br />