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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ® TANK RETROFIT E PIPING REPAIR/RETROFIT 8 UDC REPAIRIRETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Rancho San Miguel Phone# 209-339-8200 <br /> I Address <br /> L 610 S Cherokee Lane, Lodi <br /> TCross Street <br /> Y Owner/Operator Jesus Jurado Phone# 209-992-1463 <br /> o Contractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lic# 312844 CIEI C61040, Hill <br /> A Insurer Insurance Company of the West Work Comp# WPL 502190702 <br /> G ' <br /> T IGC Technicians Name M ke Briggs Expiration Date 6111/17 <br /> OICC Installer's Name <br /> R Expiration Dale <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> GR er piping 6Wnp,91 look d.t.. 1,UDC In,BIC.) Installed <br /> T <br /> A i <br /> N <br /> K r <br /> r I <br /> ✓ 1 1 <br /> P (O Approvetl Approved with conditions � Disapproved <br /> L <br /> A ( ant With Conditions) <br /> N Plan Reviewers Nam e <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS 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 <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS 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 /> OF CALIFORNIA.' <br /> Appliranrs Signature I "� TUe Compliance Officer _Dale <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit Payment coverage per tank. If <br /> the party designated below is different than the permit applicant. e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Marty Weithman TITLE Compliance Officer PHONE# (408)213-6038 <br /> ADDRESS 680 Quinn Ave. San Jose,95112 <br /> SIGNATURE I� , ,', , , ,' DATE <br /> EH230038(revised 0220)09) <br /> 1 <br />