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SA N JOAQUIN 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 V UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# CAL000448151 Project Contact&Telephone# Mushtaq Omar(510)432-5211 <br /> A <br /> C Facility Name SB Gas and Market Phone# (209) 834-8838 <br /> 1 Address 515 W 11th St Tracy, CA 95376 <br /> TCross Street Bessie Ave. <br /> Y Owner/Operator Mushtaq Omar Phone# (510) 432-5211 <br /> c Contractor Name Tank Tight systems, Inc. Phone# (916) 378-4168 <br /> O <br /> N Contractor Address 8515 Waterman Rd Elk Grove, CA 95624 <br /> T CA Lic# 1066914 Class A HAZ <br /> A Insurer Wesco Insurance Company Work Comp# WWC3507896 <br /> T ICC Technician's Name Brian Roth Sr. Expiration Date 11/15/2023 <br /> R ICC Installer's Name Manpreet Arman Expiration Date 02/27/2025 <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 UNDERGROUND 12K Unleaded Regular <br /> A UNDERGROUND 6K/6K Unleaded Supreme/Diesel <br /> N <br /> K <br /> P ❑ Approved d Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A N Plan Reviewers Name cu,\ 1vsU Date ©-1 114 I-Zt,23 <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 Title Owner Date 07/10/2023 <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 Mustaq Omar TITLE OWNER/CEO PHONE#(510) 432-5211 <br /> ADDRESS P.O.Box Exeter CA 93221 <br /> SIGNATURE - DATE 07/10/2023 <br /> 2 of 6 <br />