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SAN JDAQUIN <br />-COU NTY------ <br />RgQ <br />LVED <br />ironment <br />JUN 1,7 2021 <br />APPLICATION FOR UNDERGROUND STORAGE T'IRONMENTAL HEALTH <br />RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <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 <br />EPA Site # <br />Project Contact & Telephone # tony 916 753 0177 <br />A <br />Facility ility Name Circle K <br />Phone # 409 292 5953 <br />I <br />L <br />Address 419 S Main St <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator Hussain <br />Phone # 409 292 5953 <br />o <br />Contractor Name Tank Tight Systems Inc <br />Phone # 916 753 0177 <br />N <br />Contractor Address 8515 Waterman rd <br />CA Lic # 1066914 ClassGen A +Haz <br />T <br />R <br />Insurer Wesco <br />Work Comp # wwc3507896 <br />A <br />Q <br />T <br />ICC Technician's Name Brian Roth <br />Expiration Date <br />P 12/02/21 <br />R <br />ICC Installer's Name James Day <br />Expiration Date <br />P 11/04/2021 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Installed <br />91 Fill bucket <br />5 gallon <br />91 gasoline <br />T <br />A <br />N <br />K <br />P <br />❑ Approved <br />Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />L <br />N <br />js <br />Plan Reviewers Name � ��% <br />q <br />Date /JZD2% <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. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br />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 <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's <br />Signature Tony Mehroke <br />Title Manager Date 06/15/2021 <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 Tank Tight Systems <br />ADDRESS 8515 Waterman rd <br />SIGNATURE <br />PHONE # 916 753 0177 <br />06/15/2021 <br />