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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 REPAIRIRETROFIT ❑ UDC 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 /> L <br /> I Cross Street Joe Pombo Parkway <br /> T <br /> Y Owner/Operator Anabi Oil / Chittal Shah Phone # ( 951 ) 313 - 7490 <br /> o Contractor Name DiMaggio Maintenance , Inc . c/o Scott Willett Phone # ( 760 ) 722 - 9002 <br /> T Contractor Address 1040 Joshua Way , Vista , CA 92081 CA Lic # $ $ $ 681 ClassA, B , C- 10 , Haz <br /> A Insurer Insurance Company of the West work Comp # WSD503573005 <br /> c ICC Technician 's Name Matt DIMa 10 Expiration Date03/09/2021 <br /> T <br /> ° ICC Installer's Name p 03/29/2021 <br /> R Matt DiMa gio Expiration Date <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 R& R existing Drop Tubes at all Unleaded <br /> K UST's . Mid - Grade <br /> Premium <br /> Diesel <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( e Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date KZ'/ 3 120 zb <br /> APPLICANT MUST PERFORM ALL WOR IN CORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HE TH 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 Operations Manager Date 01 / 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 DiMaggio Maintenance , Inc . TITLE Operations Manager _PHONE # 760 ) 722 - 9002 <br /> c/o Scott Willett <br /> ADDRESS 1040 Joshua Way Vista CA 92081 <br /> SIGNATURE T59V DATE 01 / 15/2021 <br /> I� <br /> 2 of 6 <br /> i <br />