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ENVIRONMENTAL HEALTH DEPARTMLI�IfEIVED <br /> SAN JOAQUIN COUNTY JUN 0 4 20% <br /> 600 East Main Street, Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax- (209)468-3433 ENN'l1tONNlENTAL HEALTH <br /> DEPAK'pp1ENT <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 El PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Rales Phone# 209-956-9300 <br /> IAddress <br /> L 4219 Morada Lane,.Stockton CA 95212 <br /> TCross Street <br /> Y Owner/Operator Relays Phone# 916-373-6325 <br /> oContractor Name Able Maintenance Phone# 408-213-6038 <br /> T Contractor Address 3224 Regional Pkwy,Santa Rose CA 95403 CA Lic# 312844 C1858B,A,C10 <br /> A Insurer State Comp Ins Fund Work Comp# 9073129 <br /> T ICC Technician's Name Expiration Date <br /> D (CC Installer's Name <br /> R Kelly Burningham Expiration Date 1/20!2019 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (1, 87 pf fntl Sung 81 Wk-0etapta,UDC @,atm) y Installed <br /> T <br /> A <br /> N <br /> K <br /> In A <br /> P Approved Approved with conditions 0 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.' 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.' rr q' <br /> Appfiunts Sign,lure t bl•ftl we Compliance Officer Det, 5/17/2018 <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 dale below. <br /> NAME Marty Weithman TITLE Compliance Officer PHONE# 408-213-6038 <br /> ADDRESS 680 Quinn Ave.Stan Jose, 95112p <br /> SIGNATURE �( <br /> &Ag ,Vy�rj I /�' sd,4Ad DATE 5/17/2018 <br /> EH230038(revised 02/20109) <br /> 1 <br />