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RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTM.F§ITq 2018 <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202LNVIRONNIENTAL HEALTH <br /> Telephone: (209)468-3420 Fax: (209)468-3433 DEA RTNIENT <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 8 UDC REPAIRIRETROFIT B COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> D Facility Name Rales Phone# 209-956-9300 <br /> IAddress <br /> L 4219 Moreda Lane,.Stockton CA 95212 <br /> T I Cross Street <br /> Y Owner/Operator Relays Phone# 916-373-6325 <br /> o Contractor Name Able Maintenance Phone# 408-213-6038 <br /> NContractor Address 3224 Regional Pkwy, Santa Rose CA 95403 CA Lief! 312844 C18ssB.q,C10 <br /> A Insurer State Comp Ins Fund Work Comp# 9073129 <br /> T ICC Technician's Name Expiration Date <br /> DICC Installer's Name <br /> R Kelly Burnin ham Expiration Date 1/20/2019 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> Ire er PIPInD sumo.91 Wk Eeten ,UDc iQ,ek.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Ej Approved Approved with conditions (] Disapproved <br /> L (See Attachment With Conditions) <br /> A <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.' CONTRACTORS 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 /> Applicants Slamwre ee.er./bf lye Compliance Officer DkK, 5/17/2018 <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 dale below. <br /> NAME Marty Weilhman TITLE Compliance Officer PHONE# 408-213-6038 <br /> ADDRESS 680 Quinn Ave.Stan Jose,951�1�2 <br /> E CLAr � <br /> SIGNATURE a, b� I /1./K.t Y��„� Y.[ti� DATE 5/1712018 <br /> EH230038(revised 0240/09) <br /> 1 <br />