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a.' A N JOAQUIN Environmental Health Department <br /> 0 U i\l I- Y <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 /> 6TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/ RETROFIT ❑ COLD START/ EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 209-300-3488 suzanna <br /> A <br /> C Facility Name Dino mart Phone # 209-300-3488 <br /> I <br /> L Address 1001 East Yosemite ave Manteca <br /> TCross Street arlow ave <br /> Y Owner/Operator Vinash Singh Phone # 510-557-4508 <br /> CContractor Name Tony Mehroke Phone # 916 667-6891 <br /> 0 <br /> T Contractor Address 8515 Waterman RD Elk Grove CA Lic # 1066914 Class A HAZ <br /> R Insurer Wesco PN0499902B <br /> A Work Comp # <br /> cICC Technician 's Name Brian Roth <br /> T Expiration Date 12-02-21 <br /> R ICC Installer's Name James Day Expiration Date <br /> Tank system work area Date UST <br /> (Le, 87 p1pin8 sump, 91 leak detector, uoc 112, etc. ) Tank Size Chemicals Stored Currently Installed <br /> T diesel tank 4000 Diesel May- 1999 <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> L ( See Attachment With Conditions) <br /> A f <br /> N Plan Reviewers Name_ r a,� ` rjs O Date , 1 U 10 2a L <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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." c <br /> Applicant's Signature �jo �U ���Yb k�� Title Contractor Date 5/03/2021 <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 Tony Mehroke TITLE PHONE #contractor 916-667-6891 <br /> ADDRESS 8515 Waterman rd elk grove <br /> SIGNATURE �jo V\`� �� l � DATE 5/03/2021 <br /> 2of6 <br />