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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 # CAL000465466 Project Contact & Telephone # MANNY ARMAN (916) 818-8842 <br /> C Facility Name SAVE ON FUEL Phone # (209)2394700 <br /> I Address 420 W YOSEMITE AVE . , MANTECA , CA 95337 <br /> L <br /> I Cross Street JESSIE AVE . , <br /> T <br /> Y Owner/Operator JATIN ANEJA Phone # (669) 251 -7057 <br /> C Contractor Name TANK-TIGHT SYSTEMS , INC . Phone # ( 916) 667-6891 <br /> O <br /> NCA 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 # WWC3560056 <br /> C <br /> T ICC Technician 's Name BRIAN ROTH Expiration Date 11 / 14/2023 <br /> Q <br /> R ICC Installer's Name BRIAN ROTH Expiration Date 11 / 14/2023 <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 SPILL BUCKET 12 , 000 REGULAR 11 / 1998 <br /> A <br /> N <br /> K <br /> P ❑ Approved VApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A / J <br /> N Plan Reviewers Name Date <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 ( vv Title DateOFFICE ADMIN 05/ 17/2022 <br /> �litic tater. <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 MEHROKE TITLE OWNER PHONE # ( 916) 667-6891 <br /> ADDRESS 8515 WATERMAN ROAD , ELK GROVE , CA 95624 <br /> SIGNATURE I � hU CAU \� I DATE 05/17/2022 <br /> 2 of 6 <br />