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1868 E. Hazelton Avenue Stockton , California 95205 T 209 468-3420 F 209 4640138 www.s*cehd. com <br /> Environmental Health Department <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 # cl 1000461387 Project Contact & Telephone # 650-898-9051 <br /> A <br /> Facility Nam GREAT GAS PACIFIC INC Phone # (510)857-6673 <br /> L Address 61 1 PACIFIC AVE STOCKTON CA 95207 <br /> I <br /> T <br /> y Cross Street PORTER AVE <br /> Owner/Oper9tor MOHAMMAD HUSSAINI ( TANK OPERATOR) Phone # (510 )857-6673 <br /> C Contractor Nime TANK-TIGHT SYSTEMS INC <br /> 7 o Phone # (916)753-0177 <br /> N l <br /> T Contractor Address 9397 MIKO CIR, ELK GROVE CA 95624 <br /> R �f CA Lic # Class BLD2021 -0693 <br /> A Insurer WES O INSURANCE COMPANY <br /> C Work Comp # WWC3507896 <br /> T <br /> o ICC Technician 's Name MANNY DHANIJU Expiration Date 07/31 /2022 <br /> R 1 <br /> ICC Installer' Name MANNY DHANIJU Expiration Date 07/31 /2022 <br /> T Tani system work area Tank Size Chemicals Stored CurrentlyDate UST <br /> A (Le. 87 piping a p, 91 leak detector, UDC 1121 etc.) <br /> N I Installed <br /> K SPILL BUCK T - REGULAR <br /> P Approved Approved with conditions Disapproved <br /> L <br /> ) (se ttachmen onditions) <br /> N Plan Reviewers Name �� + it 4T 1 <br /> Date <br />