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SANJOAQUIN 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 ® UDC REPAIR/RETROFIT ® COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # TONY MEHROKE 916 -667-6891 <br /> C Facility Name VALERO Phone # 209 -823-7676 <br /> I <br /> L Address 1700 EAST YOSEMITE AVE <br /> I Cross Street <br /> T <br /> Y Owner/Operator SUNNY BHULLAR Phone # 209-647 -9230 <br /> c Contractor Name TANK-TIGHT SYSTEMS , INC . Phone # 916 -667-6891 <br /> 0 <br /> N Contractor Address 8515 WATERMAN ROAD , ELK GROVE , CA 95624 CA Lic # 1066914 Class A HAZ <br /> T <br /> R <br /> A Insurer WESCO INSURANCE COMPANY Work Comp # WWC3507896 <br /> 0 <br /> T ICC Technician 's Name BRIAN ROTH Expiration Date 12/14/2021 <br /> 0 <br /> R ICC Installer's Name JAMES DAY Expiration Date 11 /4/2021 <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 UNDERGROUND 12K 91 <br /> A UNDERGROUND 12K 87 <br /> N <br /> K <br /> P ❑ Approved d Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name , I Date 10 1 06 1ZJ Z j <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." r <br /> Applicant's Signature V�CYU � i Title FOREMAN Date 09/16/2021 <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 KULVIR (TONY) MEHROKE TITLE OWNER/PRESIDENT PHONE # 916 -667-6891 <br /> ADDRESS 8515 WATERMAN ROAD , ELK GROVE , CA 95624 <br /> SIGNATURE � ����� ` DATE 09/24/2021 <br /> 2 of 6 <br />