Laserfiche WebLink
SANJ 0 A Q U I N Environmental Health Department <br /> C: ( � lJ . \J I l <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> T RMIT EXPIRES 180 DAYS FROM PPROVAL DATE, INDICATE P TYPE BELOW: <br /> DANK RETROFIT WING REPAIR/RETROFITDDC REPAIR/RETROFIT OLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> C Facility Name Food Mart Gasoline Phone # 209-547-1700 <br /> I <br /> L Address 2185 E Fremont Street <br /> I Cross Street <br /> T -- <br /> Y Owner/Operator Ashish Boveja Phone # 408-204- 1636 <br /> 0 <br /> 0 Contractor Name AFFORDA TEST Phone # 209-744-0112 <br /> N Contractor Address 416 2nd Street CA Lie # 341375 Class C36 <br /> T <br /> R <br /> A InsurerState Fund Work Comp # 1916583-2022 <br /> T <br /> T ICC Technician's Name Zane Nimmo Expiration Date 05/26/23 <br /> o <br /> R ICC Installers Name Zane Nimmo Expiration Date 05/26/23 <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 87 fill drop tube 12000 87 UNLEADED 01 /01 /2000 <br /> N 91 fill droptube 5000 91 UNLEADED _ 01 /01 /2000 <br /> K diesel fill drop tube 5000 DIESEL 01 /01 /2000 <br /> P Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date 12 g � 2�6 22 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> OAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> HE 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: "1 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 /> F CALIFORNIA." � p � �q ��v� � ,.. <br /> ppiicant's Signature waR` ' Title lam" �' `� _Date 11011i � 2. 1 <br /> � � v <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. Lj l) $ ZDV I b3 b <br /> NAME AshishppBOVeja TITLE _ r PHONE # <br /> ADDRESS I C� F %*Wel 0n #)" S f" S tMC14OWN <br /> SIGNATURE DATE C I Ito I LZ) L Y ' <br /> 2of6 <br />