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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUN'T'Y <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 /> 8 TANK RETROFIT 10 PIPING REPAIRIRETROFIT rl UDC REPAIR/RETROFIT a COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#Marty Weithman 408-2136038 <br /> A <br /> C Facility Name Rancho San Miguel Food 4 Less) Phone# 209-942-2840 <br /> 1 Address y <br /> L 1409 S.Airport Way Stockton CA 95206 <br /> I Cross Street Charter <br /> T <br /> Y Owner/Operalor PAQ Inc. Phone# 209-858-0101 <br /> I'- Contractor Name <br /> Q Service Station Systems, Inc. Phone# 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lic# 485184 Classg C61/D40 HAZ <br /> R Insurer <br /> C ICW Group Work Comp# WPL502130700 <br /> T ICC Technician's Name Randy Wilkerson Expiration Date 5/19/2013 <br /> R ICC Installer's Name <br /> Expiration Dale <br /> Tank system work area Tank Size Chemicals Stored Current! Date UST <br /> (i.e 87 piping pump,61 kak defector,UpG 1f2,etc.) y <br /> Installed <br /> T <br /> A <br /> N <br /> K L L <br /> v <br /> b <br /> P Approved Approved with conditions 15 Disapproved <br /> L ( ee chment With Conditions) <br /> A <br /> N Plan Reviewers Name <br /> Dake <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: 9 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT <br /> TO 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.' ll f <br /> Appiicanrssignawre �2 [� ��'��L U ' L�-int-{1 ti-,t-,, Compliance Officer D,� 611 512 0 1 2 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff lime 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 J t c k 4.-1'.-r L (C t l L-� 1 �. ppTE 6/15/2012 <br /> EH230038(revised 09/20109) <br /> 1 <br />