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V :v . �_. - <br />Environment <br />• <br />e f <br />APPLICATION FOR UNDERGROUNDSTORAGE <br />23 <br />RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL <br />• eHEALTH <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE w w r <br />VICES <br />F <br />EPA Site # <br />Project Contact &Telephone # <br />Brian Able 408-938-7116 <br />� <br />Facility Name A Gas - Food Mart <br />Phone # 209-707-3191 <br />Address 2115 W Yosemite Manteca, CA 95337 <br />L <br />_ <br />TCross <br />Street S AlrpglLY�(ay _ <br />a.. <br />Y <br />_ _ <br />OwnedOp erator Annie Gurreet Sandhu <br />Phone # 209-707-3191 <br />c <br />Contractor Name Service Station Systems Inc. <br />Phone # 408-938-7116 <br />0 <br />NCA <br />Address 680 Quinn Ave. San Jose, CA 95112 <br />CA Lic # <br />485184 Class B/C61-D401Haz <br />T <br />R <br />Insurer SCF National Insurance Company <br />Work Comp # 4046603 <br />C <br />ICC Technician's Name Kris Bell <br />Expiration Date 7/2212024 <br />T <br />ICC installer's Name Kris Bell <br />Expiration Date 7/2212024 <br />R <br />Tank system work area <br />Tank Size <br />Chemicals <br />Stored Currently <br />Date UST <br />(is, 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions <br />❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />C 2..b 12,)U <br />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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />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 />Project Manager <br />6/19/2023 <br />Applicant's <br />Signature ��_ Title <br />Date <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 Brian Able TITLE Project <br />ADDRESS <br />SIGNATOR <br />680 Quinn Ave, San Jose, CA 95112 <br />Manager PHONE # <br />6/1912023 <br />6/19/2023 <br />