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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 to UDC REPAIR/RETROFIT ® COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # TONY MEHROKE 916 -667-6891 <br /> C Facility Name DIAMOND GAS AND FOOD MART Phone # 209 -823 -8800 <br /> I <br /> L Address 824 EAST YOSEMITE AVENUE , MANTECA 95336 <br /> Cross Street <br /> T <br /> Y Owner/Operator KAL NOOR Phone # 510 -305 -0787 <br /> c Contractor Name TANK-TIGHT SYSTEMS , INC . Phone # 916 667 6891 <br /> 0 <br /> N <br /> T Contractor Address 8515 WATERMAN ROAD CA Lic # 1066914 Class A HAZ <br /> R <br /> A Insurer WESCO INSURANCE COMPANY Work Comp # WWC3507896 <br /> C <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 112, etc.) Installed <br /> T UNDERGROUND 12K 87 <br /> A UNDERGROUND 6K SPLIT 89 <br /> N <br /> K UNDERGROUND 6K SPLIT 91 <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L /Vine Attachment With Conditions) <br /> N Plan Reviewers Name Date � a <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." <br /> Applicant's Signature w.�Yb � Title OWNER/PRESIDENT 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 956k,� <br /> 24 <br /> SIGNATURE o DATE 09/24/21 <br /> 2 of 6 <br />