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ENVIRONMENTAL HEALTH DEPAR�1 VED <br /> SAN JOAQUIN COUNTY cEp 16 2G16 <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 EhVIROh;,`lENTAL HEALTH <br /> PERMIT/SEROCES <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 /> EI TANK RETROFIT [0 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 6 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> G Facility Name Woodbridge Arco Phone# 209-339-8238 <br /> IAddress <br /> L 18806 Lower Sacramento Rd,Woodbridge CA 95258 <br /> TCross Street <br /> Y Owner/Operator Jessie Bola Phone# 916-834-9436 <br /> GContractor Name Service Station Systems, Inc. Phone# <br /> o Y 408-213-6038 <br /> N Contractor Address 680 Quinn Avenue CA Lic# 485184 ClassB, C61/D40, Hb <br /> AInsurer Insurance Company of the West Work Comp WPL 5021907 04 <br /> D ' Expiration Date <br /> 11/24/2017T ICC Technicians Name Brian McPheely <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently <br /> Dale UST <br /> lie er olP�no steep.91 ink aaeaa,UDC @,etc) Y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved ,Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <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 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.' 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' \ <br /> Appliwnrs signatum Jic .L.0 ti-b �- � Lt z cTI`ne�-Compliance Officer Dai 9/14/2016 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage par 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, 1 95112 <br /> SIGNATURE 1I.��C ( ��hti%L "--� L1,(�L—C�{ �- DATE 9/14/2016 <br /> EH230038 trevised 02/20109) <br /> 1 <br />