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SA N s10 A Q U I N 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 XUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Scott Willett/ 760 722 - 9002 <br /> A Facility Name Phone# 760 722 - 9002 <br /> C Anabi Oil - Shell ( ) <br /> I Address 2375 West Grant Line Road, Tracy, CA 95377 <br /> T Cross Street Joe Pombo Parkway <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 Industry St., Oceanside, CA 920541 CA Lic# 888681 Class A B Haz <br /> A Insurer Insurance Company of the West work Comp#WSD503573000 <br /> T ICC Technician's Name Rodney DiMaggio Expiration Date 12/21/2017 <br /> R ICC Installer's Name Rodney DiMaggio Expiration Date 12/07/2017 <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 All UDC Sumps <br /> A All UST Sums STP & Fill Unleaded <br /> N <br /> K Mid-Grade <br /> Premium <br /> Diesel <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S Att hment With Conditions) <br /> A 4- <br /> N Plan Reviewers Name Date `/ 3o <br /> ll 7 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC TH 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 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 Project Manager Date 07/20/2017 <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 Project Manager PHONE# 760) 722 - 9002 <br /> c/o Scott Willett <br /> ADDRESS 2603 Industry Street, Oceanside, CA 92054 <br /> SIGNATURE DATE 07/20/2017 <br /> 2 of 6 <br />